Lynne Pinkney

Spontaneous development of bilateral subdural hematomas in an infant with benign infantile hydrocephalus: color Doppler assessment of vessels traversing extra-axial spaces

We present an infant with macrocrania, who initially demonstrated prominent extra-axial fluid collections on sonography of the brain, compatible with benign infantile hydrocephalus (BIH). Because of increasing macrocrania, a follow-up sonogram of the brain was performed; it revealed progressive enlargement of the extra-axial spaces, which now had echogenic debris. Color Doppler US showed bridging veins traversing these extra-axial spaces, so it was initially thought that these spaces were subarachnoid in nature (positive cortical vein sign). However, an arachnoid membrane was identified superior to the cortex, and there was compression of true cortical vessels beneath this dural membrane. An MRI of the brain showed the extra-axial spaces to represent bilateral subdural hematomas. The pathogenesis of spontaneous development of the subdural hematomas, in the setting of BIH, is discussed. We also emphasize that visualizing traversing bridging veins through extra-axial spaces does not necessarily imply that these spaces are subarachnoid in origin.

Sclerosing stromal tumor of the ovary in a premenarchal female

Abstract. Sclerosing stromal tumor (SST) is a rare benign ovarian neoplasm of stromal origin with less than 100 cases reported in the literature. Unlike the other stromal tumors, thecomas and fibromas, which tend to occur in the fifth and sixth decades, sclerosing stromal tumors predominantly affect females in the second and third decades. Computed tomography (CT), magnetic resonance imaging (MRI), and ultrasound findings have been described, but have not been reported previously in the pediatric literature. We present a case of SST of the ovary in a 10-year-old premenarchal female, the youngest patient to our knowledge reported in the literature, and describe the ultrasound and CT findings with pathologic correlation.

Relative distribution of pertinent findings on portable neonatal abdominal radiographs: can we shield the gonads?

BackgroundShielding of the gonads is a dose-saving strategy in pediatric radiography and its use is the law in New York and the majority of other states. However, routine use of gonadal shields is controversial because of concerns that important diagnostic information can be obscured.ObjectiveThe purpose of this study was to assess the frequency and spatial distribution of key findings on portable neonatal abdominal radiographs.Materials and methodsWe reviewed the 2,544 portable neonatal intensive care unit anteroposterior abdominal radiographs performed in 2010 at a university medical center, of which 962 were inadequately shielded. These 962 radiographs were reviewed by pairs of pediatric radiologists for the presence of findings in different regions, including bowel abnormalities, pneumatosis, free air, inguinal hernias, osseous abnormalities, and catheter/tube tips.ResultsThe fewest pertinent findings were present below the level of the sacrosciatic notches (n = 181, 18.8%). Of the 853 abnormalities below the level of the iliac crests in our cohort, six were isolated to these regions, whereas others had concomitant abnormalities more superiorly. Of 35 radiographs with pneumatosis or suspected pneumatosis in the pelvis, 33 had pneumatosis in more superior regions. Suspected free air was never isolated to the pelvis. Osseous abnormalities were only present in the pelvis below the sacrosciatic notch, and 37.5% of lower extremity catheters terminated below the level of the sacrosciatic notches.ConclusionPertinent findings on neonatal intensive care unit abdominal radiographs are rarely isolated to the pelvic regions.

The efficacy of digital fluoroscopic image capture in the evaluation of vesicoureteral reflux in children

BackgroundIn accordance with ALARA, minimizing radiation exposure associated with voiding cystourethrograms (VCUG) is of critical importance. Advances in fluoroscopic technology might help achieve this goal.ObjectiveTo determine the efficacy of fluoroscopic image capture compared to conventional digital radiographic spot (DRS) images in voiding cystourethrograms (VCUG) for the evaluation of vesicoureteral reflux (VUR) in children.Materials and methodsThe study was a retrospective review of 65 VCUG examinations (130 kidney/ureter units). Each examination consisted of fluoroscopically captured spot (FCS) images and the corresponding DRS images. Each set of images was evaluated by three pediatric radiologists for the diagnosis of VUR for a total of 390 kidney/ureter units reviewed. Using the DRS image set as the reference standard, the efficacy of the FCS images for diagnosing reflux was determined.ResultsThe diagnostic accuracy of the FCS images in terms of the binary characterization of reflux as negative or positive was 97.2% (379/390). The sensitivity of the FCS images was 92.6% (88/95); the specificity of the FCS images was 98.6% (291/295).ConclusionFluoroscopically captured images are adequate in documenting absence of VUR on VCUG examinations, obviating the need for radiographic spot images and resulting in reduction in radiation exposure.

Idiopathic intraparenchymal hematoma of the liver in a neonate

Hepatic hematomas in newborn infants are not frequently detected clinically, but are often found at perinatal autopsies. These hematomas of the liver are usually subcapsular in location. A variety of etiologies for such hematomas has been implicated, such as trauma, sepsis, and coagulopathies. We present a neonate who presented with jaundice and abdominal distention. Initial imaging studies revealed a large intraparenchymal lesion of the liver, which was at first thought to be suspicious for neoplasm; however, MRI showed the lesion to be hemorrhagic and follow-up sonographic studies showed total resolution of this lesion, compatible with hematoma. The intraparenchymal location and the idiopathic nature of this lesion distinguish this case from others previously reported.

Abnormal alignment of the left lower extremity and irregular gait

Focal fibrocartilaginous dysplasia (FFCD) is a rare benign entity first described by Bell in 1985 [1]. The most common site of FFCD is the proximal tibia followed by distal femur, forearm, humerus, phalanx, and vertebra transverse process [2, 3]. FFCD is most commonly noticed when children start crawling and ambulating [4]. Usual presentation is unilateral tibia vara, limb shortening, and tibial torsion [4]. Etiology of FFCD is not completely known. It is believed to be a failure of differentiation of a mesenchymal anlage, resulting in excessive fibrocartilage formation and interfering with growth of the medial tibial metadiaphysis and natural slipping of the periosteum for growth [1, 3]. In proximal tibia, this lesion typically occurs in the region of pes anserine tendons insertion [5]. Prior insult to the medial tibia has been postulated as an etiology [4, 5]. The characteristic radiographic findings are tibia vara associated with an elliptical lucency within the medial tibial metadiaphyseal cortex with surrounding sclerotic bone and absence of cortical margin at the superomedial aspect of the lesion [6]. The cortical thickening is more pronounced along the lateral margin of the lesion [7]. On CT, the corresponding lucency contains the insertion of the pes anserine tendons. MRI demonstrates characteristic low-signal T1 and T2 intraosseous soft tissue component corresponding to the cortical lucency, surrounded by hypointense sclerotic bone [2]. The signal intensity of the soft tissue component is hypointense to the hyaline cartilage, similar to fibrocartilage. Post-contrast images as in our case typically do not display significant enhancement [7]. FFCD is typically a radiographic diagnosis and CT and MRI should be reserved for problem solving and/or operative planning. Recognition of this entity on radiographs could have prevented our case from undergoing further imaging. Correct diagnosis of FFCD is crucial to avoid unnecessary invasive procedures. Differential diagnosis for tibia vara in children includes infantile Blount’s disease, rickets, and asymmetric closure of the epiphysis secondary to infection or trauma [3]. Blount’s disease typically involves the epiphysis and metaphysis and can present bilaterally as opposed to FFCD, which is typically unilateral without direct involvement of the growth plate [4]. Rickets usually involves more than one bone and is accompanied by classic metaphyseal flaring and growth plate widening and can present at the age of 2 in severe cases [8]. Osteoid osteoma in the medial tibia can potentially cause tibia vara. Osteoid osteoma has a lucent nidus, which can be centrally mineralized, and is usually surrounded by reactive sclerotic bone and is seen in a wide age range [9]. On certain imaging slices, FFCD can mimic the appearance of nonmineralized osteoid osteoma nidus, while superomedial cortical bone defect in FFCD can differentiate the diagnosis. Due to the classic imaging findings, biopsy is generally not recommended. For cases that have undergone biopsy, pathology demonstrated dense hypocellular fibrous tissue interspersed with foci resembling fibrocartilage [1]. The presence of fibrocartilage is not essential for diagnosis [6]. Approximately 45% of the cases of tibial FFCD have spontaneously resolved over the span of approximately 57 months, which may be an underestimation of cases that could potentially spontaneously regress if intervention had not been performed [6]. Conservative management has been recommended if the Levin–Drennan angle, measured by the intersection The case presentation can be found at https://doi.org/10.1007/s00256018-2912-x