The heart of pediatric radiology

Hermes

Classic metaphyseal lesion of distal tibia following footling breech delivery Abstract Classic metaphyseal lesions associated with childbirth are rare. We report a distal tibial metaphyseal fracture following a difficult breech delivery. Classic metaphyseal fractures are considered highly specific injuries associated with non-accidental trauma. This case depicts a classic metaphyseal lesion sustained during footling breech extraction in an urgent delivery. The traction and torque placed on the distal extremities during this difficult delivery suggest a potential mechanism for this injury.

Active reviewers (from October 1, 2018 through September 30, 2019)

Denying the abusive head trauma denialists their day in court, one step at a time

Prenatal evaluation of the Sakoda complex Abstract Sakoda complex is a rare but distinct combination of birth defects consisting of a basal cephalocele, agenesis of the corpus callosum, and midline cleft lip/palate. It has been reported in association with ophthalmologic abnormalities, cognitive deficits and severe epilepsy. Here we describe both prenatal and postnatal MRI findings of a classic case of Sakoda complex in a child with characteristic findings on fetal MRI; prenatal findings have not been described in the literature. Diagnosis of this entity has important implications for prenatal counseling and perinatal management, as is demonstrated in this case.

Ultrasound detection of crystal gel ball ingestion in children

A multifactorial severity score for left congenital diaphragmatic hernia in a high-risk population using fetal magnetic resonance imaging Abstract Background Adverse outcomes for infants born with left congenital diaphragmatic hernia (CDH) have been correlated with fetal imaging findings. Objective We sought to corroborate these correlations in a high-risk cohort and describe a predictive mortality algorithm combining multiple imaging biomarkers for use in prenatal counseling. Materials and methods We reviewed fetal MRI examinations at our institution from 2004 to 2016 demonstrating left-side CDH. MRI findings, hospital course and outcomes were recorded and analyzed using bivariate and multivariable analysis. We generated a receiver operating curve (ROC) to determine a cut-off relation for mortality. Finally, we created a predictive mortality calculator. Results Of 41 fetuses included in this high-risk cohort, 41% survived. Per bivariate analysis, observed-to-expected total fetal lung volume (P=0.007), intrathoracic position of the stomach (P=0.049), and extracorporeal membrane oxygenation (ECMO) requirement (P<0.001) were significantly associated with infant mortality. Youden J statistic optimized the ROC for mortality at 24% observed-to-expected total fetal lung volume (sensitivity 64%, specificity 82%, area under the curve 0.72). On multivariable analysis, observed-to-expected total fetal lung volume ± 24% was predictive of mortality (adjusted odds ratio, 95% confidence interval: 0.09 [0.02, 0.55]; P=0.008). We derived a novel mortality prediction calculator from this analysis. Conclusion In this high-risk cohort, decreased observed-to-expected total fetal lung volume and stomach herniation were significantly associated with mortality. The novel predictive mortality calculator utilizes information from fetal MR imaging and provides prognostic information for health care providers. Creation of similar predictive tools by other institutions, using their distinct populations, might prove useful in family counseling, especially where there are discordant imaging findings.

Association between ventricular shunt catheter calcifications and the development of shunt fracture Abstract Background Calcifications along ventricular catheters have been associated with shunt fractures although it is unknown whether their development predicts whether and when the shunts will fracture. Objective To determine whether extracranial calcifications found on a radiographic shunt series predicts whether a patient will experience a shunt catheter fracture or complication. Materials and methods A retrospective review was performed of pediatric patients with a ventricular shunt placed before 18 years of age and radiographic shunt series. Two thousand, six hundred and thirty shunt series in 523 patients (301 male) were reviewed to identify the development of calcifications around the catheter and fracture. Fifty-one patients were excluded for preexisting calcifications with shunt fracture. (48) Absence of shunt (2) or age (1). Analysis included descriptive statistics, odds ratio and chi-square test results. Results Four hundred seventy-two patients were included. Of the 59 shunts in 58 patients that developed calcifications, 23 went on to fracture (39%). Forty shunts without calcification in 37 patients developed fractures. There is a significant positive association between calcification and fracture (Χ2=39.1, P<0.01). It is 6.12 times more likely that a fractured shunt had calcifications compared to a non-fractured shunt having calcifications. Calcifications appeared within an average of 9 years, 10 months (range: 4-14 years) after shunt insertion. Shunt fractures occurred within an average of 5 years, 2 months (range: 6 months-9 years) after the appearance of calcifications with a median patient age of 14.6 years. Nearly all fractures were at or adjacent to the calcifications, most commonly in the neck (17/23; 73.9%). Conclusion Shunt calcification represents a significant risk for catheter fracture in the pediatric population. Early intervention or closer interval follow-up may be indicated in those found to have calcifications.

2-D magnetic resonance spectroscopic imaging of the pediatric brain using compressed sensing Abstract Background Magnetic resonance spectroscopic imaging helps to determine abnormal brain tissue conditions by evaluating metabolite concentrations. Although a powerful technique, it is underutilized in routine clinical studies because of its long scan times. Objective In this study, we evaluated the feasibility of scan time reduction in metabolic imaging using compressed-sensing-based MR spectroscopic imaging in pediatric patients undergoing routine brain exams. Materials and methods We retrospectively evaluated compressed-sensing reconstructions in MR spectroscopic imaging datasets from 20 pediatric patients (11 males, 9 females; average age: 5.4±4.5 years; age range: 3 days to 16 years). We performed retrospective under-sampling of the MR spectroscopic imaging datasets to simulate accelerations of 2-, 3-, 4-, 5-, 7- and 10-fold, with subsequent reconstructions in MATLAB. Metabolite maps of N-acetylaspartate, creatine, choline and lactate (where applicable) were quantitatively evaluated in terms of the root-mean-square error (RMSE), peak amplitudes and total scan time. We used the two-tailed paired t-test along with linear regression analysis to statistically compare the compressed-sensing reconstructions at each acceleration with the fully sampled reference dataset. Results High fidelity was maintained in the compressed-sensing MR spectroscopic imaging reconstructions from 50% to 80% under-sampling, with the RMSE not exceeding 3% in any dataset. Metabolite intensities and ratios evaluated on a voxel-by-voxel basis showed no statistically significant differences and mean metabolite intensities showed high correlation compared to the fully sampled reference dataset up to an acceleration factor of 5. Conclusion Compressed-sensing MR spectroscopic imaging has the potential to reduce MR spectroscopic imaging scan times for pediatric patients, with negligible information loss.