Rebecca Stein-Wexler

Giant cystic abdominal masses in children

In this pictorial essay the common and uncommon causes of large cystic and cyst-like abdominal masses in children are reviewed. We discuss and illustrate the following: mesenchymal hamartoma, choledochal cyst, hydrops of the gallbladder, congenital splenic cyst, pancreatic pseudocyst, pancreatic cystadenoma, hydronephrosis, multicystic dysplastic kidney, multilocular cystic nephroma, adrenal hemorrhage, mesenteric and omental cysts, gastrointestinal duplication cyst, meconium pseudocyst, ovarian cysts and cystic neoplasms, hematocolpos, urachal cysts, appendiceal abscess, abdominal and sacrococcygeal teratoma, and CSF pseudocyst. We also describe imaging features and clues to the diagnosis.

MR imaging of soft tissue masses in children.

This article discusses the role of MR imaging in the evaluation of musculoskeletal soft tissue masses, reviewing limitations in its ability to establish tissue diagnosis and its critical role in determining lesion extent. It also reviews benign soft tissue masses, such as fibrous lesions, popliteal cysts, lipomatous lesions, and neurofibromatous tumors. Reactive entities, such as abscess, myositis ossificans, and hemangioma, are discussed. Differentiation between high- and low-flow vascular and lymphatic anomalies is reviewed. The article concludes with a discussion of the uncommon malignant musculoskeletal soft tissue tumors, focusing on infantile fibrosarcoma, rhabdomyosarcoma, synovial sarcoma, and granulocytic sarcoma.

Pediatric Soft Tissue Sarcomas

After a brief discussion of the rarity of soft tissue sarcomas in children and of the limited ability of magnetic resonance imaging to provide a tissue diagnosis, this article discusses the incidence, presentation, treatment, prognosis, and imaging characteristics of the more common and unusual pediatric soft tissue sarcomas. It begins with extensive discussion of rhabdomyosarcoma, synovial sarcoma, and congenital/infantile fibrosarcoma. It then presents a more abbreviated discussion of uncommon tumors such as alveolar soft part sarcoma, epithelioid sarcoma, extraosseous Ewings sarcoma, granulocytic sarcoma, hemangiopericytoma, liposarcoma, malignant fibrous histiocytoma, malignant peripheral nerve sheath tumor, and undifferentiated sarcoma.

Comparison of Computed Tomography and Chest Radiography in the Detection of Rib Fractures in Abused Infants.

PURPOSE Chest radiographs (CXR) are the standard method for evaluating rib fractures in abused infants. Computed tomography (CT) is a sensitive method to detect rib fractures. The purpose of this study was to compare CT and CXR in the evaluation of rib fractures in abused infants. METHODS This retrospective study included all 12 abused infants identified from 1999 to 2004 who had rib fractures and both CXR and CT (8 abdomen CTs, 4 chest CTs). CT exams had been performed for clinical indications, and were obtained within one day of the CXR. Studies were reviewed by two pediatric radiologists to determine the number, locations, and approximate ages of the rib fractures. A total of 225 ribs were completely (192) or partially (33) seen by CT, and the matched ribs on CXR were used for the analysis. RESULTS The mean patient age was 2.5 months (1.2-5.6), with seven females and five males. While 131 fractures were visualized by CT, only 79 were seen by CXR (p<.001). One patient had fractures only seen by CT. There were significantly (p<.05) more early subacute (24 vs. 4), subacute (47 vs. 26), and old fractures (4 vs. 0) seen by CT than by CXR. Anterior (42 vs. 11), anterolateral (21 vs. 12), posterolateral (9 vs. 3) and posterior (39 vs. 24) fractures were better seen by CT than by CXR (p<.01). Bilateral fractures were detected more often by CT (11) than by CXR (6). CONCLUSIONS While this study group is small, these findings suggest that CT is better than CXR in visualizing rib fractures in abused infants.

Follow-Up Skeletal Surveys for Suspected Non-Accidental Trauma: Can a More Limited Survey Be Performed without Compromising Diagnostic Information?.

OBJECTIVE Follow-up skeletal surveys have been shown to improve the rate of fracture detection in suspected cases of non-accidental trauma (NAT). As these studies are performed in a particularly radiosensitive population, it is important to evaluate if all of the (approximately 20) radiographs obtained at repeat skeletal survey are clinically useful. Our goal was to evaluate if certain radiographs can be excluded at follow-up skeletal survey without compromising the clinical efficacy. METHODS This retrospective study included 22 cases of suspected NAT (average age 3.8 months, range 0.7-15 months) in which patients received both initial and follow-up bone surveys. The follow-up survey was performed an average of 16.7 days (range 11-29 days) after the initial survey. Radiographs were reviewed by 2 pediatric radiologists, with discrepancies resolved by consensus. In addition, we combined our data with data from all known previously published reports of follow-up skeletal surveys for NAT for meta-analysis. RESULTS A total of 36 fractures were found on the initial bone survey in 16/22 patients (73%). Six patients had no fractures detected at initial survey. Follow-up bone surveys demonstrated an additional 3 fractures (2 extremities and 1 rib) in 3/22 cases (14%); 1 was in a patient whose initial survey was negative. No additional fractures in the skull, spine, pelvis, feet, or hands were detected in any case. In combination with patients reported in the literature (194 patients total) no new fracture of the skull, spine, pelvis, or hands was detected at follow-up survey. The skull, spine and pelvis radiographs are the highest dose-exposure studies of the skeletal survey. CONCLUSION AND PRACTICE IMPLICATIONS If no injury is detected or suspected in the pelvis, spine, hands, or skull at initial bone survey for suspected NAT, a limited follow-up skeletal survey which excludes the pelvis, lateral spine, hands, and skull should be considered to limit radiation exposure without limiting diagnostic information.

An interactive teaching device simulating intussusception reduction

Intussusception is relatively uncommon, occurring in 0.5 to 2.3 cases per 1,000 live births in the USA. Radiology residents, therefore, have few opportunities to participate in intussusception reduction during training, and practicing radiologists encounter it infrequently. Training is essential, as successful reduction avoids surgery. The judgment involved in reducing an intussusception is best gained with experience. We developed a training device that simulates fluoroscopic intussusception reduction with air. The device consists of a doll that contains a cylinder with similar stress and strain characteristics to the human colon. The trainee pumps air into the cylinder through a rectal tube using a standard hand-held air reduction pump. A sensor measures the pressure within the chamber and transmits readings to a computer, which displays images from actual intussusception reductions based on the pressure maintained within the device. A random component in the software gives the user a new experience each time and models uncertainties in the actual reduction process, including perforation. This intussusception reduction simulator can enhance resident education, giving residents the opportunity to practice this technique before employing it on a real patient. The simulator can also help practicing radiologists become more comfortable with intussusception air reduction.

Rib head protrusion into the central canal in type 1 neurofibromatosis

BackgroundIntraspinal rib head dislocation is an important but under-recognized consequence of dystrophic scoliosis in patients with neurofibromatosis 1 (NF1).ObjectiveTo present clinical and imaging findings of intraspinal rib head dislocation in NF1.Materials and methodsWe retrospectively reviewed clinical presentation, imaging, operative reports and post-operative courses in four NF1 patients with intraspinal rib head dislocation and dystrophic scoliosis. We also reviewed 17 cases from the English literature.ResultsIn each of our four cases of intraspinal rib head dislocation, a single rib head was dislocated on the convex apex of the curve, most often in the mid- to lower thoracic region. Cord compression occurred in half of these patients. Analysis of the literature yielded similar findings. Only three cases in the literature demonstrates the MRI appearance of this entity; most employ CT. All of our cases include both MRI and CT; we review the subtle findings on MRI.ConclusionAlthough intraspinal rib head dislocation is readily apparent on CT, sometimes MRI is the only cross-sectional imaging performed. It is essential that radiologists become familiar with this entity, as subtle findings have significant implications for surgical management.

2015 RAD-AID Conference on International Radiology for Developing Countries: The Evolving Global Radiology Landscape

Abstract Radiology in low- and middle-income (developing) countries continues to make progress. Research and international outreach projects presented at the 2015 annual RAD-AID conference emphasize important global themes, including (1) recent slowing of emerging market growth that threatens to constrain the advance of radiology, (2) increasing global noncommunicable diseases (such as cancer and cardiovascular disease) needing radiology for detection and management, (3) strategic prioritization for pediatric radiology in global public health initiatives, (4) continuous expansion of global health curricula at radiology residencies and the RAD-AID Chapter Network’s participating institutions, and (5) technologic innovation for recently accelerated implementation of PACS in low-resource countries.

Radiology residents’ experience with intussusception reduction

BackgroundResidents should be exposed to adequate procedural volume to act independently upon completion of training. Informal inquiry led us to question whether residents encounter enough intussusception reductions to become comfortable with the procedure.ObjectiveWe sought to determine radiology residents’ exposure to intussusception reductions, and whether their experiences vary by region or institution.Materials and methodsU.S. radiology residency program directors were asked to encourage their residents to complete a 12-question online survey describing characteristics of their pediatric radiology department, experiences with intussusception reduction, and confidence in their own ability to perform the procedure.ResultsSix hundred sixty-four residents responded during the study period. Of those, 308 (46.4%) had not experienced an intussusception reduction, and 228 (34%) had experienced only one or two. Twenty-two percent of fourth-year residents had never experienced an intussusception reduction, and 21% had experienced only one. Among second- through fourth-year residents, only 99 (18.3%) felt confident that they could competently reduce an intussusception (P < 0.0001), and 336 (62.2%) thought they would benefit from a computer-assisted training model simulating intussusception reduction (P < 0.0001).ConclusionRadiology residents have limited opportunity to learn intussusception reduction and therefore lack confidence. Most think they would benefit from additional training with a computer-simulation model.

Floating–Harbor syndrome and intramedullary spinal cord ganglioglioma: Case report and observations from the literature†

We report on a 5‐year‐old male with expressive language delay, developmental delay, short stature, and facial anomalies consistent with Floating–Harbor syndrome (FHS). In addition, he developed an intramedullary ganglioglioma. This is the first reported case of a tumor associated with FHS, and may represent an as yet undefined genetic link between spinal cord tumors and FHS, adding this syndrome to the growing list of disorders with a predisposition for tumor development.