Rafael Rivera

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.

Time‐resolved dynamic contrast‐enhanced MR urography for the evaluation of ureteral peristalsis: Initial experience

To determine the feasibility of time‐resolved dynamic contrast‐enhanced magnetic resonance urography (MRU) for the evaluation of ureteral peristalsis using a data‐sharing 3D gradient echo sequence with spiral k‐space filling.

Primary bacterial peritonitis in otherwise healthy children: imaging findings

We report the imaging findings of two recent cases of primary bacterial peritonitis in otherwise healthy children with a clinical presentation mimicking acute appendicitis. Primary bacterial peritonitis is rare in the absence of underlying systemic disease. Although it has been described in the pediatric literature, the imaging findings have not been described in the radiological literature to the best of our knowledge. With imaging playing an increasing role in the evaluation of appendicitis in children, it is important for the radiologist to be familiar with this inflammatory process.

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.

Calcified catheter “cast” masquerading as a retained catheter fragment after removal of an implanted venous access device

Calcified catheter “cast” found on radiologic studies after central venous catheter removal is a rare complication that has been reported twice. Both cases were associated with thrombus. In this case report, we present a 15-year-old boy with acute lymphoblastic leukemia who demonstrated on CT scan a radiopacity in his left brachiocephalic vein after removal of an implanted venous access device. This was initially thought to be a retained catheter fragment. Diagnostic studies, including venogram, excluded the presence of a retained catheter fragment. Additional procedures to retrieve a nonexistent catheter fragment were thus avoided. Therefore, a catheter “cast” should be considered as part of the differential diagnosis when calcification is found on an imaging study after removal of an implantable venous access device to prevent an unwarranted surgical exploration.

An appendiceal leiomyoma in a child with acquired immunodeficiency syndrome

Children with acquired immunodeficiency syndrome (AIDS) are at an increased risk for lymphoproliferative and neoplastic disorders. Included among these are smooth muscle neoplasms such as leiomyomas and leiomyosarcomas. There have been at least 15 reported cases of smooth muscle tumors in the approximately 8,000 children with AIDS, however the incidence in immunocompetent children is only two per ten million. The lesions in children with human immunodeficiency virus infection are usually found in the lung, liver, and gastrointestinal tract. Here, we present an unusual case of a 12-year-old African American girl with vertically acquired AIDS who presented to the pediatric emergency department with severe diffuse abdominal pain. She was ultimately found to have an appendiceal leiomyoma on abdominal exploration, the first reported case. Our report suggests that smooth muscle tumors of the appendix be included in the differential diagnosis of abdominal masses in children with AIDS.

Tuberculous splenic abscess in a neonate with thrombocytopenia

We present a case of a premature neonate who presented with anemia and persistent thrombocytopenia. The patient was ultimately diagnosed with disseminated tuberculosis. Initial sonographic evaluation of the abdomen revealed a heterogeneous but predominately hypoechoic spleen; there was subsequent evolution of a splenic abscess. The patient was treated medically with anti-tubercular drugs. Follow-up post-treatment sonograms of the spleen showed diminution of the abscess and the evolution of multiple calcifications compatible with calcified granulomas. This case is an unusual presentation of tuberculosis in an infant with splenic abscess associated with thrombocytopenia and anemia.

Epidural air in child with spontaneous pneumomediastinum.

A 3-year-old boy was seen in the emergency room after his mother noted neck swelling, drooling, and dysphonia. This occurred after a brief coughing episode and one episode of vomiting. Although hewas never diagnosed with asthma, the patient had a history of severe paroxysms of coughing. On examination, he had palpable subcutaneous emphysema of the neck, upper chest, and upper back. There were bilateral rhonchi (low pitched, snore-like sounds) on lung examination. He had no neurologic deficits. A chest X-ray showed significant subcutaneous emphysema of the soft tissues of the neck and chest. A neck and chest computed tomography (CT) scan (►Figs. 1 and 2) showed severe pneumomediastinum with extensive subcutaneous emphysema tracking along the fascial planes of the neck, supraclavicular regions, right upper extremity, anterior chest wall, and epidural space. He underwent an esophagram which was negative for perforation. He was observed in the hospital for a day and discharged to home the next day. During this hospitalization he was diagnosed with asthma and is currently being treated for such.