Salinas Puente Estefany,  Blanqueto Fuentes David,  Rodríguez Garza Claudia,  Dávila Escamilla Ivan,  Montemayor Martínez Alberto

Final Pr. ID: Poster #: CR-001

Intracranial hemorrhage (ICH) and ischemic brain injury are rare in the fetus. The most common location of hemorrhage in the fetus is intraventricular and is related to prematurity. Intracranial hemorrhage in the fetus can be intra or extra-axial and its recognition is important because of its complications and poor outcome. The causes of fetal intracranial hemorrhage are idiopathic, maternal, and of the fetus; maternal causes vary, and the main is trauma. Domestic violence increases during pregnancy, placing the mother and the fetus at risk for injury.
Features of central nervous system nonaccidental trauma in pediatric patients are well established, however, there are not too many examples in the literature of these imaging findings in the fetal stage.
The purpose of this case is to demonstrate the features of intracranial hemorrhage and ischemic brain injury caused by nonaccidental trauma during pregnancy and the evolution after birth.
The subject of this case report is a 36-week gestation product referred because of severe ventriculomegaly detected during an obstetric ultrasound; a fetal MRI was performed which showed an acute to subacute hemispheric bilateral subdural hematoma, infratentorial subdural hemorrhage, retroclival hematoma, subarachnoid hemorrhage, ventriculomegaly, brain edema, and midline shift. The patient was born at 38 weeks through C-section with no respiratory effort and a 4 points APGAR score, he was intubated and spent 38 days in the NICU, during his stay a postnatal transfontanelar ultrasound and a brain MRI were performed and showed persistence of the supratentorial and infratentorial subdural hematomas bigger in size with an epidural component, retroclival hematoma, subarachnoid hemorrhage, brain edema, midline shift, uncal herniation and hemispheric ischemic vascular event. The etiology of this extensive and atypical presentation hemorrhage was inquired including coagulation and genetic disorders, and the medical background of the parents which came out normal; after thorough interrogation, the mother revealed trauma related to domestic violence.
In our case, we will show that the localization and features of nonaccidental trauma of the central nervous system in the fetal stage are similar to the pediatric stage. Read More

Authors:  Salinas Puente Estefany,  Blanqueto Fuentes David,  Rodríguez Garza Claudia,  Dávila Escamilla Ivan,  Montemayor Martínez Alberto

Keywords:  Fetal ,  Trauma ,  Head

Riemann Monique,  Bisbing Brecken,  Goncalves Luis,  Ramasubramanian Aparna

Final Pr. ID: Poster #: CR-002

PFV is a rare congenital orbital malformation in which there is failure of the hyaloid artery to regress causing a persistent vasculature within the vitreous portion of the eye. Patients present with leukocoria that can be unilateral or bilateral. The most concerning differential diagnosis is retinoblastoma. We present three case studies referred for evaluation to exclude retinoblastoma in which MFI assisted in making the diagnosis of PFV. Imaging was perfomed with a high frequency linear array transducer and established preset in accordance with FDA guidelines.
When characterizing orbital masses, early and accurate diagnosis is crucial to the patient’s prognosis. Ultrasound can be a superior method due to its ability to visualize superficial structures and detect slow velocity blood flow. While CD and SD are able to determine direction and velocity of flow, MFI improves the sensitivity and ability to display microvascularities.

Case 1
Three-month-old male with right eye leukocoria. Ultrasound demonstrated smaller right than left globe. A triangular retrolental amorphous and heterogeneous soft tissue mass was present. A mass with fibrovascular stalk containing a persistent hyaloid artery was observed with layering debris. Left orbit was normal. Findings consistent with right PFV.

Case 2
Six-week-old female with left eye leukocoria. Ultrasound demonstrated a normal right globe. The left globe had a hyperechogenic triangular mass extending from the posterior margin of the lens to the optic nerve. A persistent hyaloid artery was noted. The posterior margin of the lens was irregular. A small amount of subretinal fluid over lied the optic nerve. Findings consistent with left PFV.

Case 3
Newborn male with microphthalmia and possible cataractous lens. Ultrasound demonstrated right globe with lens intact, anechoic and normally located. A hyperechogenic mass with ill-defined borders extends from the posterior aspect of the lens to the retina along the central aspect of the globe. No calcifications were observed. Blood flow noted within a persistent hyaloid artery. The triangular portion of the mass attached to the lens also demonstrated increased microvascularity. Left globe with intact lens which was anechoic and normally located. Evaluation of the left posterior chamber demonstrates a similar-appearing mass with a persistent hyaloid artery. Findings consistent with bilateral PFV. Read More

Authors:  Riemann Monique,  Bisbing Brecken,  Goncalves Luis,  Ramasubramanian Aparna

Keywords:  orbital ,  persistent fetal vasculature ,  micro flow imaging

Goncalves Luis,  Patel Mittun,  Wermers Josh,  Simmons Curtis,  Vaughn Jennifer,  Pfeifer Cory,  Cornejo Patricia

Final Pr. ID: Poster #: CR-003

Kagami-Ogata syndrome (KOS) is a rare and potentially underdiagnosed imprinting disorder caused by paternal uniparental disomy for chromosome 14 or microdeletions and epimutations involving differentially methylated regions (DMRs) at 14q32.2. Depending on phenotypic expression, KOS may mimic trisomy 18 and asphyxiating thoracic dysplasia. Therefore, awareness is essential for prenatal diagnosis. Coat hanger ribs as seen by x-rays have been reported as s pathognomonic sign but have not been reported prenatally. Herein we present images of the coat hanger ribs as seen by low-dose computerized tomography (CT) as well as detailed imaging of the multiple phenotypic features by ultrasound and MRI of KOS in two cases seen prenatally. Case 1: G1P0 singleton pregnancy had fetal echocardiogram at 25 weeks due to concern for congenital heart disease, thickened nuchal fold and thickened skin of the thoracic wall. The exam showed left superior vena cava draining to coronary sinus, dilated right atrium and right ventricle, total anomalous pulmonary venous return, and hydrops. Skin edema was redemonstrated by follow up US at 29 weeks. Fetal MRI and follow-up US at 32 weeks showed polyhydramnios, diffuse skin edema, prominent cheeks and frontal bossing by 3D US, mild shortening of the ulna and right clubfoot, and a bell-shaped thorax by MRI. Chromosomal microarray was positive for terminal deletion of 14q32.2, consistent with KOS. Coat hanger ribs were present on postnatal x-rays. The patient is G-tube and tracheostomy tube dependent, has global developmental delay, neuromuscular scoliosis, left hip subluxation, wrist contractures and planovalgus feet at the age of 2 ½ years. Case 2: G3P1, singleton pregnancy with negative non-invasive prenatal testing (NIPT). US performed at 29 weeks showed polyhydramnios, clenched hands, and bell-shaped small thorax. Multimodality fetal imagin (US, MRI and CT) at 32 weeks showed a narrowed elongated thorax by US and MRI but ribs were poorly visualized. Additional anomalies included polyhydramnios, rhizomelic bone shortening, clenched hands, and prominent cheeks by 3D US. Low-dose CT showed coat hanger ribs. Postnatal x-rays confirmed coat hanger ribs and other abnormalities. Postnatal genetic testing showed paternal uniparental disomy for chromosome 14, consistent with KOS. The patient has restrictive lung disease due to hypoplastic thoracic cage, hypotonia, scoliosis, developmental delay, and umbilical hernia at 13 months. Read More

Authors:  Goncalves Luis,  Patel Mittun,  Wermers Josh,  Simmons Curtis,  Vaughn Jennifer,  Pfeifer Cory,  Cornejo Patricia

Keywords:  kagami-ogata ,  fetal MRI ,  fetal CT

Alkhudari Anas,  Galal Maad,  Aljabr Aljoharah

Final Pr. ID: Poster #: CR-004

In the treatment of infant hydrocephalus, ventriculoperitoneal (VP) shunts are considered the standard of care. Various complications are associated with VP shunting. Ventriculoperitoneal shunt catheter migration remains a rare but documented complication seen in one in 1000 patients who receive a VP shunt. Migration of the VP shunt into the scrotum is even more uncommon and requires surgical treatment.

We report a unique case of a 6-month-old preterm male with history of hydrocephalus treated with surgically placed VP shunt. He presented with vomiting and was found to have a right inguinoscrotal sac swelling with the tip of the catheter appreciated upon palpation of the sac and later confirmed by abdominal radiograph. After admission, the patient started to show rapid and significant improvement without significant intervention. On further imaging, the positioning of the VP shunt improved with a sufficiently reduced tip highlighting the spontaneous reduction of the distal catheter tip. Repeated imaging months later showed no recurrence.

Scrotal migrations are more common in children, and this is commonly thought to be due to an unobliterated processus vaginalis allowing the catheter tip to enter the scrotal sac. As most patients remain asymptomatic and present only after an exacerbation with co-infections, the importance of early diagnosis should not be neglected. This is crucial to avoid subsequent complications such as acute hydrocephalus, testicular torsion, and peritoneal perforation. For nearly all scrotal VP shunt migration cases, definitive treatment is surgical with manual repositioning followed by hernia repair. VP shunt migration should remain an essential differential of scrotal masses in that patient population. We also want to raise awareness to radiologists about the malposition of the VP shunt catheter and the rare ability for it to reduce and retract into appropriate positioning spontaneously. We believe that these recommendations will help improve quality of care management in pediatric hydrocephalus patients. Read More

Authors:  Alkhudari Anas,  Galal Maad,  Aljabr Aljoharah

Keywords:  Hydrocephalus ,  Ventriculoperitoneal Shunt Migration ,  Scrotal Sac Swelling

Weitz Daniel,  Torres Manuel,  Zandieh Arash

Final Pr. ID: Poster #: CR-005

Biliary atresia is an inflammatory cholangiopathy of the neonatal period that may lead to future fibrosis and obliteration of both intra and extrahepatic biliary ducts. It is an uncommon disease that can be further classified by morphology. The rare, atypical Type IIA variant results in absence of the common hepatic duct, but patent cystic and common bile duct, occasionally accompanied by a hilar cyst (so-called “cystic biliary atresia”) or otherwise normal-appearing gallbladder.

In this educational case exhibit, we present a premature, former 31-week newborn with neonatal hyperbilirubinemia who was ultimately diagnosed with a type IIA biliary atresia and treated with the Kasai procedure. Abdominal ultrasound showed a contracted gallbladder, and subsequent HIDA scans showed no radiotracer excretion into the common bile duct or small bowel. Surgery and GI were consulted, and the patient underwent the Kasai procedure. The intraoperative cholangiogram confirmed type IIA biliary atresia and postoperatively there was a general downward trend of transaminases and direct bilirubin. In our discussion, we will be reviewing this patient’s uncommon morphology of biliary atresia, key radiologic findings and surgical- pathologic correlation, along with subsequent care and management for this condition. Read More

Authors:  Weitz Daniel,  Torres Manuel,  Zandieh Arash

Keywords:  Kasai ,  Hyperbilirubinemia ,  cholangiogram

Panesar Harsimran,  Beekman Alexander,  Martin Laura,  Armstrong Katherine,  Hodes Aaron

Final Pr. ID: Poster #: CR-006

Midgut volvulus in children is uncommon, but diagnosis of portal vein thrombosis in association with midgut volvulus has been rarely reported. We present a case of a 3-year old male with an unusual presentation of recurrent episodic abdominal pain suspected initially having ileocolic intussusception. Cross-sectional imaging identified extensive acute portomesenteric thrombosis in the setting of suspected midgut volvulus, which was confirmed on upper GI series and at surgery. A thrombophilia workup was negative. To our knowledge, this is the first case of acute portal vein and superior mesenteric vein thrombosis with splenic vein extension in association with midgut volvulus. When the diagnosis remains elusive and imaging demonstrates an extensive acute PVT with SMV extension in children and adolescents, radiologists should consider midgut volvulus in addition to other etiologies, such as malignancy, cirrhosis, or bowel inflammation. Read More

Authors:  Panesar Harsimran,  Beekman Alexander,  Martin Laura,  Armstrong Katherine,  Hodes Aaron

Keywords:  Portal vein thrombosis ,  Superior mesenteric vein thrombosis ,  Midgut volvulus

Relan Ramit,  Lawrence Charles

Final Pr. ID: Poster #: CR-007

Internal hernias are a rare cause of chronic abdominal pain and bowel obstruction in pediatric patients. Furthermore, congenital trans-mesenteric hernias constitute only 5–10% of internal hernias. Internal paraduodenal hernias are more common in adults secondary to postoperative mesentery defects. However, transmesenteric hernias in children are caused from a congenital defect in small bowel mesentery near the ileoceclal region or ligament of trietz.

The subject of the case report is a 17 year old male who presented to primary care for several weeks of chronic abdominal pain and recurrent billious emesis. Initial abdominal radiographs demonstrated no evidence of obstruction. The patient presented to radiology for CT evaluation which demonstrated herniated loops of mid small bowel in the left hemiabdomen through a mesenteric defect. Patient was taken to the operating room for an elective exploratory laporotomy which demonstrated herniated loops of jejunum at the mesenteric defect near the ligament of trietz. The herniated loops of jejunum were anchored to duodenum and the mesenteric defect was closed. Patient tolerated the surgery without any complications and reports resolution of symptoms.

Trans-mesenteric hernias are difficult to diagnose due to lack of specific physical symptoms or laboratory findings to confirm the suspicion. Therefore, imaging findings play a vital role in diagnosis. CT imaging is useful to evaluate for mesenteric defects, obstruction and ischemia. Internal hernias with congenital mesenteric defects should be included in the differential for chronic abdominal and small bowel obstructions. Read More

Authors:  Relan Ramit,  Lawrence Charles

Keywords:  Internal hernia ,  Congenital mesenteric defect

Epps Caleb,  Smith Benjamin

Final Pr. ID: Poster #: CR-008

A 13-year-old male presented to the emergency department with acute penile shaft swelling and pain after falling in the shower onto a partially erect penis. Initial ultrasound of the penis demonstrated a hypoechoic collection within the right ventrolateral midshaft, adjacent to an apparent focal discontinuity of the tunica albuginea. Additionally, a normal appearing urethra was identified. The patient was emergently brought to the operating room where a correlating tunica albuginea defect was not identified (via artificial erection with saline injection into the right corpora cavernosa), suggesting the absence of a penile fracture. Follow-up penile MRI revealed a urethral duplication, with injury to the ventral aspect of the dorsal urethra and an adjacent complex fluid collection. This represented a peri-urethral hematoma/urinoma. The ventral urethra was intact and unremarkable, accounting for the normal urethra visualized sonographically.

Urethral duplication is a rare congenital anomaly characterized by two urethras with variation in their location and courses. Type IIA 2 (Effman classification; seen in this patient) is the most complex form where there is proximal fusion of the two urethras prior to bladder insertion. Clinical manifestations vary but include penile deformation, urinary incontinence, and urinary tract infections. Traumatic urethral injury seen in patients with duplication is rare with no case reports found on literature review. Moreover, penile fracture mimics are not common as a clinical scenario and sonographic findings are relatively specific. The presented case demonstrates a rare scenario that may serve as a penile fracture mimic. Read More

Authors:  Epps Caleb,  Smith Benjamin

Keywords:  Duplicated Urethra ,  Penile Fracture ,  Urethral Injury

Burgos Daylen Sire,  Park Halley

Final Pr. ID: Poster #: CR-009

An 8-year-old female with Poland syndrome of the left chest initially presents to be considered for reconstructive surgery. On the preoperative MRI, along with the expected hypoplastic left hemithorax including the ribs, pectoralis major, and minor muscles, there is the absence of a left ovary in the pelvis and left kidney. Furthermore, there is an incidental 9 mm multicystic structure at the anterior spleen. No further workup was done at that time. After undergoing reconstructive surgery as well as scoliosis, occasional chest pain is experienced 10 years later. During the clinical workup, incidentally noted on the CT chest with contrast is increased anterior splenic hypodensity. The possibility for ectopic ovary or splenogonadal fusion was raised as well as involuted or atrophic multicystic dysplastic kidney, neoplasm, or vascular malformation.
Initial workup included the US which revealed a 3.3 cm nonspecific lesion with posterior acoustic enhancement and without substantial internal vascularity. MRI of the spleen was performed which revealed a multicystic lesion, with imaging characteristics highly suggestive of an ectopic left ovary containing multiple physiologic follicles, from splenogonadal fusion. The uterus is also noted to be a right-sided unicornuate uterus. Furthermore, tiny non-communicative cystic changes in a linear manner left lateral to the psoas muscle, were identified, which may represent involuted/atretic remnant of the left multicystic dysplastic kidney. Read More

Authors:  Burgos Daylen Sire,  Park Halley

Keywords:  Ectopic ,  Ovary ,  splenogonadal

Foo Madeline,  Nicol Kathleen,  Murakami James

Final Pr. ID: Poster #: CR-010

Chondroblastomas (CBs) are rare benign bone tumors that usually present within the first two decades of life, are more common in males, and originate within the epiphysis of long bones. In this same age group, Aneurysmal Bone Cysts (ABCs) commonly occur. ABCs are benign expansile osteolytic lesions which can be primary, occurring in isolation, or they can occur alongside other bone tumors such as CBs. CBs are one of the most common tumors to present with associated ABC-like changes. CBs and ABCs are often difficult to treat because of their locations. To minimize operative morbidity, especially in hard-to-reach lesions, percutaneous approaches for both lesions have been individually described. We present a skull base CB with associated ABC-like changes treated by combining two different previously described percutaneous modalities.

A 17-year-old healthy male presented with neck and shoulder pain. Imaging revealed an expansile lytic bone tumor replacing the clivus and left occipital condyle. The lesion was predominantly cystic with blood-fluid levels on T2W images but also had a 1 cm diameter dark nodular area in the left side of the clivus that was initially felt to be blood products rather than a solid tumor nodule. Pathology later revealed that this nodular area was a CB and the adjacent cystic portions were ABC-like changes. The CB was treated with Radiofrequency Ablation (RFA) and the adjacent ABC areas with doxycycline sclerotherapy. After 3 years of follow-up, there has been no clinical or radiological evidence of recurrence. RFA was complicated by a hypoglossal nerve injury. Otherwise, he had complete resolution of all symptoms and has returned to all activities including collegiate athletics. Read More

Authors:  Foo Madeline,  Nicol Kathleen,  Murakami James

Keywords:  Chondroblastoma ,  ABC ,  Tumor Ablation

Foo Madeline,  Mcdaniel Janice

Final Pr. ID: Poster #: CR-011

Pseudoaneurysms are uncommon vascular abnormalities contained by surrounding adventitial and perivascular tissues, often caused by a disruption of the arterial wall secondary to arterial injury or inflammation. Post-traumatic and iatrogenic pseudoaneurysms in children are especially rare, contributing to the insufficient literature regarding their care. Traditional treatment in adults for these lesions include surgical repair and angiography with embolization. Recently, minimally invasive endovascular techniques, such as percutaneous ultrasound-guided thrombin injection (UGTI), have become the first-line therapeutic choice for certain types of pseudoaneurysm. We present 3 patients with pseudoaneurysms treated with UGTI in uncommon locations.

Cases:
Case 1: 6-year-old female with trauma to the spleen from a bike accident who later developed a 1.6cm pseudoaneurysm of the spleen, which was treated with an injection of thrombin using ultrasound guidance.
Case 2: 9-year-old female with trauma to the lower leg after falling through a glass table who developed a 3.8cm pseudoaneurysm off the anterior tibial artery, which was treated with an injection of thrombin using ultrasound guidance.
Case 3: 13-year-old female with a 2.3cm iatrogenic pseudoaneurysm off the gluteal artery related to percutaneous transgluteal abscess drain placement, which was treated with an injection of thrombin using ultrasound guidance. Read More

Authors:  Foo Madeline,  Mcdaniel Janice

Keywords:  Pseudoaneurysms ,  Ultrasound-Guided Thrombin Injection ,  Pediatric IR

Wallworth Taylor,  Husson Christopher,  Rooks Veronica,  Roberie Dustin

Final Pr. ID: Poster #: CR-012

Pilomatricomas (PM), benign neoplasms of the hair follicle matrix cells, present in the pediatric population with a slight female predominance. These neoplasms are the second most commonly excised pediatric skin mass and comprise up to 10% of superficial masses evaluated by pathologists. Typically, they present as a slow growing, solitary, painless, superficial mass in the head and neck.

We present a unique case of trauma preceding rapid development of an abnormally large PM. No cases with such characteristics currently exist in the literature.

A preschool aged girl presented with a two-month history of an enlarging superficial scalp mass following local trauma. The parents reported that she was running, fell, and hit her head on the ground. The patient reported minor pain, discoloration and local swelling, but was otherwise well with no loss of consciousness. One week post-injury, the family noticed a persistent “mosquito-bite sized bump” at the site of scalp trauma. Over the next two months, the “bump” steadily enlarged to the size of a ping pong ball, prompting evaluation. The patient denied associated pain, itching, or drainage. Exam noted a well-appearing girl with a round, well-marginated, firm, painless 3.0 cm mass at the left frontotemporal scalp.

Given the reported trauma, CT was performed and demonstrated a superficial scalp mass measuring 2.8 x 3.1 cm with internal calcifications and no underlying fracture or bony involvement. Sonographic evaluation showed a well-marginated, heterogeneous mass with a hypoechoic rim and internal doppler flow revealing spectral arterial and venous waveforms. MRI revealed a peripherally enhancing mass with foci of internal susceptibility. Core needle biopsy yielded fragments of epithelium composed of follicular matrix cells and aggregates of shadow cells.

A successful surgical excision was performed yielding the final pathologic diagnosis of a PM. She had an uncomplicated postoperative course.

Our case illustrates a unique case of PM, in which there was an atypical history of preceding trauma and rapid enlargement, resulting in clinical uncertainty. Unfortunately, PM’s are frequently misdiagnosed or under-considered by radiologists on initial ultrasound evaluation, despite being a common entity. Our case underscores the importance of maintaining a high suspicion for PM when evaluating a superficial mass in pediatric patients. This may reduce unnecessary and invasive procedures in the pediatric patient population. Read More

Authors:  Wallworth Taylor,  Husson Christopher,  Rooks Veronica,  Roberie Dustin

Keywords:  Pilomatrixoma ,  Calcifying Epithelioma of Malherbe

Masso Maldonado Sarina,  Dragusin Iulian,  Byerly Douglas,  Clark Paul

Final Pr. ID: Poster #: CR-013

As a flat and irregular bone of the appendicular skeleton, the scapula has a zonal classification of anatomy that is both useful for surgical planning as well as for distinctive locations of common and uncommon bone neoplasms (1). The acromion and glenoid together are grouped into the S2 zone of the scapula with the remaining scapular blade and spine comprising zone S1. This unique anatomy of the scapula may present a challenge to radiologists when distinguishing between benign and malignant bone tumors that are more commonly seen in long bones. As the S2 zone is much like a metaphyseal equivalent in long bones, the more common lesions encountered there will include giant cell tumors, aneurysmal bone cysts, chondroid neoplasms, and osteomyelitis. Bone lesions of zone S1 will more commonly include tumors such as osteochondromas, Ewings sarcoma, and Lymphoma (2).
We present a case series of osteoid osteoma, chondroblastoma, osteomyelitis, T-cell Lymphoma, and Ewings sarcoma of the scapula and shoulder girdle in children aged 7 weeks to 17 years of age. The purpose of this case series is to present a variety of common and uncommon bone lesions of the scapula and shoulder girdle in children. Through the description and defining features of these lesions, radiologists may better familiarize themselves with the surgical anatomy of the scapula to develop a narrowed and accurate differential diagnosis of pediatric scapular tumors. Read More

Authors:  Masso Maldonado Sarina,  Dragusin Iulian,  Byerly Douglas,  Clark Paul

Keywords:  Musculoskeletal ,  Scapula ,  shoulder

Steinberg Julie,  Kristeva Mariya,  Barhaghi Krystle,  Tao Ting

Final Pr. ID: Poster #: CR-014

The case report will present imaging findings from two companion cases of adolescent athletes presenting with palpable thigh masses. Patient A underwent ultrasound and MR and was diagnosed with a degloving injury of the rectus femoris. Patient B also presented with a thigh mass, and following MR underwent attempted aspiration and biopsy. The patient was then diagnosed with inflammatory myositis based on pathology from the biopsy and subsequently evaluated by rheumatology. Following review of the imaging by pediatric radiologists, a degloving injury was then diagnosed and the patient was referred to orthopedics for further management. The exhibit will review the imaging features of this uncommon injury as well as review the complex anatomy of the rectus femoris muscle.
A degloving injury represents an injury to the rectus femoris in which the inner bipennate portion of the indirect myotendinous complex is separated from the surrounding outer unipennate portion of the muscle, which results in separation and retraction of the inner muscle belly from the outer muscle belly. It differs from typical injury to the indirect myotendinous junction in in which there is no dissociation of the inner and outer components of the muscle. Awareness of this injury will help avoid misdiagnosis of soft tissue mass and unnecessary interventions. Images included in the case report will include ultrasound and two MRs. Read More

Authors:  Steinberg Julie,  Kristeva Mariya,  Barhaghi Krystle,  Tao Ting

Keywords:  myotendinous injury ,  rectus femoris ,  musculoskeletal

Ciotola-koch Jason,  Yu Brian,  Edquist Mitchell,  Thomas Richard,  Pierce Drew

Final Pr. ID: Poster #: CR-015

Emphysematous osteomyelitis is a known, though rare, diagnosis which can occur in pediatric patients and can be definitively diagnosed on computed tomography (CT). To our knowledge, only 30 cases had been reported as of 2018. Our objective is to raise awareness of emphysematous osteomyelitis as an important imaging diagnosis with high morbidity and mortality. Additionally, we aim to describe the characteristic appearance utilizing CT as a gold standard, discuss underlying etiologies, and describe associated systemic findings illustrated in a case example. In pediatric patients without comorbidities, the most common causative organism of emphysematous osteomyelitis is Fusobacterium necrophorum. F. necrophorum infection commonly causes Lemierre’s syndrome, however, the two diagnoses can coexist. With the distinct CT appearance of emphysematous osteomyelitis, radiologists can alert clinicians to the diagnosis and expedite aggressive treatment.

Our patient, an 18-year-old male with a recent outpatient diagnosis of mononucleosis, presented to the emergency department (ED) for throat pain and fever. Physical examination and lab values were remarkable for posterior pharyngeal erythema and elevated serum creatinine (1.44). He was discharged with supportive management and corticosteroids. Ten days later, he returned to the ED with worsening symptoms including right hip and right ankle pain and swelling, chest pain, and dark urine output. Physical exam was significant for tachycardia, tachypnea, and right lower quadrant abdominal pain. Laboratory evaluation showed increasing serum creatinine of 2.9, leukocytosis, thrombocytopenia, and lactic acidosis. Workup showed right lung consolidation, right pleural effusion, retroperitoneal inflammation, and emphysema about the right psoas major, as well as intramedullary air within the right ilium. The patient was admitted to the pediatric intensive care unit (PICU), received broad-spectrum intravenous antibiotics, and underwent CT-guided right ilium biopsy. Bone marrow culture grew F. necrophorum, prompting additional workup including a chest CT and head and neck CTA to assess for Lemierre’s Disease. Exams demonstrated a left parapharyngeal abscess, left internal jugular vein thrombosis, multiple cavitating pulmonary septic emboli, and bilateral pleural effusions. Anticoagulation was initiated and antibiotics were narrowed to culture sensitivities. The patient improved, allowing transfer out of the PICU to the medicine floor. Read More

Authors:  Ciotola-koch Jason,  Yu Brian,  Edquist Mitchell,  Thomas Richard,  Pierce Drew

Keywords:  Osteomyelitis ,  Lemierre's ,  Fusobacterium

Gagliano Bryce,  Freathy Sarah,  Timmons Charles,  Koral Korgun

Final Pr. ID: Poster #: CR-016

A 14 year old female without relevant past medical history presented to the ED with progressive difficulty walking, urinating and upper back pain. Physical exam demonstrated lack of proprioception within the right great toe, partial proprioception in the left great toe as well as diminished pain sensation throughout the left greater than right lower extremity. Additionally, there was prolonged clonus of the right ankle and absent clonus of the left ankle. Read More

Authors:  Gagliano Bryce,  Freathy Sarah,  Timmons Charles,  Koral Korgun

Keywords:  Astroblastoma

Riemann Monique,  Goncalves Luis,  Ramasubramanian Aparna,  Abruzzo Todd

Final Pr. ID: Poster #: CR-017

Retinoblastoma is an aggressive malignant tumor and the most common malignant intraocular tumor in children. The key to better treatment is early detection, before it metastasizes. We aim to provide better quantifiable measurements to assist the clinician in the evaluation of tumor response.
Currently, 2D sonography is performed to confirm the diagnosis, and after each sequential treatment. Thus, a change in tumor size during treatment is made by 2D evaluation only. Three-dimensional (3D) ultrasonography is an enhancement of the ultrasonographic technique that allows an examiner to obtain, non-invasively, 3D volumetric images. 3D ultrasound imaging is primarily performed in the Ob/Gyn setting. However, more and more it is being used for other areas of the body. We think that 3D technology may be particularly useful since retinoblastomas can have very irregular shapes and, therefore, simpler techniques to estimate volumes such as the performance of three orthogonal two-dimensional measurements multiplied by 0.523 to estimate the volume of an oval structure using the ellipsoid formula may be unreliable. We present several case studies performed at our institution with a developed protocol for such imaging along with the results of the study. Read More

Authors:  Riemann Monique,  Goncalves Luis,  Ramasubramanian Aparna,  Abruzzo Todd

Keywords:  orbital ,  3D ,  retinoblastoma

Uncanin Nedeljko,  Kuzminski Christopher

Final Pr. ID: Poster #: CR-018

Parechovirus is generally asymptomatic in older children and can cause symptoms similar to that of the common cold. However, in infants less than 3 months, infection can be severe with seizures and sepsis-like presentations. Currently, there are no good treatments. Some providers have administered IVIG, but the efficacy is unknown. Most patients will recover with supportive care, however neonates can have long-term consequences. The Parechovirus A3 strain has been more prevalent in circulation over the summer of 2022, such that the Center for Disease Control and Prevention has issued a health alert about the unusually high prevlalence of the A3 strain in neonates and young infants. We present a case of meningoencephalitis with unique imaging findings on MRI with Parechovirus detection in CSF studies. Although few descriptions exist within the radiology literature, our case has MRI imaging characteristics are nearly identical to that of a case series published in the American Journal of Neuroradiology in August 2019. Given the increased prevalence of this virus and radiology findings consistent with the prior publication, the imaging findings on MRI can prove to be vital in assisting with the diagnosis of patients where CSF cannot be obtained. Read More

Authors:  Uncanin Nedeljko,  Kuzminski Christopher

Keywords:  encephalitis ,  meningitis ,  parechovirus

Basavalingu Deepashri,  Perez Francisco

Final Pr. ID: Poster #: CR-019

Herein, we present a case series of children who underwent glial tumor resection with bioabsorbable plates used for craniotomy closure. On follow up MRI as part of tumor surveillance, restricted diffusion was observed in the scalp and extradural space that was initially concerning for tumor recurrence/ seeding. However, after correlation with CT, the sites of restricted diffusion corresponded closely to the sites of bioabsorable plate placement. On additional follow up imaging, the restricted diffusion resolved nearly completely in all patients. Based on literature search and histopathology, we concluded that aforementioned findings are related to delayed inflammatory reaction to the bioabsorbable plates. Read More

Authors:  Basavalingu Deepashri,  Perez Francisco

Keywords:  Glioma ,  Diffusion ,  Craniotomy

W Mustapha Wan Irfan

Final Pr. ID: Poster #: CR-020

Myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) is a distinct CNS inflammatory disease with symptoms and imaging findings that overlap with other neuroinflammatory disorders. We reported a 12-year-old girl with no known medical illness presented with gradually worsening blurring vision, and nearly blindness, associated with headache with a pain score of 2-5/10. The blurring vision started 1 week ago, initially over the right eye, then the left eye 3 days later, and subsequently, visual loss bilaterally. On examination, the pupil is 6 mm but has no perception of light. On fundoscopy, noted in both eyes: swelling, elevated, blurred margin, pink, dilated tortuous blood vessels, normal fovea reflex, no macula star, also no vitiritis or retinitis. The CNS examination is unremarkable. The patient then underwent a CT scan of the brain showed apart from right mastoiditis, no significant abnormality was detected in the brain parenchyma. Noted C3/C4 levels were normal; T4/TSH levels were normal, and ESR was 62 (raised). Since the CT brain finding was normal, we proceeded with an MRI of the brain, which showed leptomeningeal enhancement. Both retrobulbar intra-orbital segments of optic nerves appear symmetrical and swollen until the intracranial compartment just before the optic chiasm with enhancement is observed post-gadolinium. Both optic discs are also bulging in keeping with papilloedema. Both intra-orbital fats were streaky. The patient then had a lumbar puncture, and the result was normal. Serum aquaporin 4 is negative; however, the MOG antibody is detected. The patient was diagnosed with Myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) and was given intravenous immunoglobulin (IVIg) for 5 days and steroids. Upon discharge, the patient's vision improves by up to 80%. Other differentials could be neuromyelitis optica spectrum disorder (NMOSD) or multiple sclerosis (MS). It is important to get a correct and early diagnosis of MOGAD because the prognosis and treatment for MOGAD are different from those for NMOSD and MS. Read More

Authors:  W Mustapha Wan Irfan

Keywords:  MOGAD ,  Brain ,  MRI

Goldstein Elianna,  White Elena,  Giamanco Nicole,  Rooks Veronica

Final Pr. ID: Poster #: CR-021

Langerhans cell histiocytosis (LCH) is a rare neoplastic disorder of abnormal proliferation of Langerhans cells affecting predominantly pediatric populations; sites of involvement include cutaneous, osseous, hematopoietic, and multisystem disease (1). Cutaneous involvement is common in children, though thymic involvement is rarely described (2). We report a case of an 8-month-old female infant with a dyad of cutaneous and thymic LCH. The purpose of this paper is to highlight a potentially underdiagnosed manifestation of infantile LCH and consider thymic sonography in infant LCH staging evaluation.

A one-month old female presented with skin lesions and pruritus suspicious for atopic dermatitis failing to respond to therapy. Punch biopsy demonstrated cutaneous LCH. Staging non-contrast chest computed tomography (CT) showed multiple very faint calcifications in the thymus (figure 1) which could have been obscured by intravenous contrast administration. Ultrasound demonstrated multiple echogenic foci in the thymus (figure 2). Pathology confirmed thymic LCH. Throughout her presentation, the patient’s clinical symptoms of LCH were limited to diffuse pruritic cutaneous lesions. Thymic involvement changed patient management to chemotherapy infusion. At the time of this report she has shown no signs of disease progression and she remains clinically stable. Read More

Authors:  Goldstein Elianna,  White Elena,  Giamanco Nicole,  Rooks Veronica

Keywords:  Langerhans Cell Histiocytosis ,  Ultrasound ,  Thymus

Barr Lori,  Coticchia James

Final Pr. ID: Poster #: CR-022

Exudative tracheitis is the most common life-threatening acute airway abnormality in children and is usually associated with infections. Post-extubation obstructive fibrinous tracheal pseudomembrane is a rare early complication following intubation with less than 53 reports in the literature, the majority in adults.
A 12-year-old was intubated in the field when found unresponsive. The patient was transferred to the pediatric Intensive care unit where a drug overdose was diagnosed and the patient was soon extubated. Five days later, the patient experienced acute respiratory distress. Soft tissue neck radiographs demonstrated nodularity and narrowing of the subglottic portion of the trachea. A subsequent neck CT and MRI also demonstrated subglottic/tracheal irregularity and a cylindrical filling defect. The intraluminal membrane was removed via bronchoscopy with subsequent tracheal debridement. Pathologic examination revealed a fibrinous pseudomembrane.
The imaging appearance of exudative tracheitis is not specific and can be seen with infectious tracheitis, necrotizing tracheitis, and, as in this case, obstructive fibrinous tracheal pseudomembrane. Obstructive fibrinous tracheal pseudomembrane occurs following tracheal intubation with cuffed or cuffless tubes, tracheostomy tubes, and after tracheal stenting. It has also been reported in patients with gastroesophageal reflux disease. It usually presents in the early days following extubation in cases associated with endotracheal tubes. It is thought to be a very early post-traumatic response and precursor to tracheal stenosis. Since patients are often weak following recent illnesses requiring airway intervention, their symptoms may be minimal until the airway is critical and the condition is life-threatening. This is a surgical emergency. Diagnostic confirmation by flexible bronchoscopy is followed by treatment with rigid bronchoscopy. This should not be delayed by the performance of imaging studies. If diagnostic imaging is performed, the findings of airway wall irregularity and subglottic or deeper intraluminal soft tissue density material, especially if the shape mimics the endotracheal device (cylindrical), are diagnostic of exudative tracheitis including infectious, iatrogenic and reflux-related post-traumatic causes. A high index of suspicion on the part of the radiologist has the potential to decrease time-to-treatment and thus decrease complications such as tracheal stenosis and death. Read More

Authors:  Barr Lori,  Coticchia James

Keywords:  pseudomembranous ,  tracheitis ,  computed tomography

Ebai Jerky,  Nicholas Jennifer,  Foust Alexandra

Final Pr. ID: Poster #: CR-023

An afebrile 23-month-old boy with history of VSD, PFO and GERD who presented with one day of acute left sided abdominal pain, nausea and vomiting. Following a benign clinical work-up only significant for mild leukocytosis and transient small bowel to small bowel intussusception on abdominal US, he was discharged home. He re-presented a few days later with worsening abdominal pain and low grade fever and was found to have increased leukocytosis and elevated CRP. KUB demonstrated a new left lower lobe opacity. Non-contrast CT abdomen showed a well circumscribed ovoid hyperdense soft tissue mass in the inferomedial left lower lobe, a small left pleural effusion, and adjacent passive atelectasis. On chest MRI , the left lower lobe soft tissue mass demonstrated T1 isointense to hyperintense and STIR hypointense signal with mild restricted diffusion and no enhancement on post-contrast images. MRA of the chest was negative for any feeding vessel extending to the lesion. Video-assisted thoracotomy surgery revealed a torsed, bluish left lower lobe mass adherent to the mediastinum with thrombosed vessels at its pedicle. Pathology results confirmed the suspected diagnosis of an infarcted and hemorrhagic extralobar pulmonary sequestration.

Pulmonary sequestration is a rare congenital malformation of the foregut, where a nonfunctional supranumary segment of the lung lacking a normal connection to the tracheobronchial tree develops below the normal lung bud. The sequestration can be intralobar or extralobar, depending on the pleural investment, has arterial supply from systemic circulation, and venous drainage via pulmonary and/or systemic venous drainage. Torsed pulmonary sequestrations are extremely rare and occur when the sequestration twists around the axis of its vascular pedicle resulting in ischemia or infarction of the non-functional lung tissue. In the case of a full torsion, the vascular supply may not be visualized at imaging. Thus it is important to consider pulmonary sequestration as a differential diagnosis in a pediatric patient presenting with lower chest or abdominal pain with a circumscribed lower lobe pulmonary mass, even without characteristic feeding vessels on MRI/MRA. Read More

Authors:  Ebai Jerky,  Nicholas Jennifer,  Foust Alexandra

Keywords:  Pulmonary ,  Sequestration ,  Torsed

Dhangana Pinky,  Tadros Sameh

Final Pr. ID: Poster #: CR-024

Background: Langerhans cell histiocytosis (LCH) is common in adult smokers but exceedingly rare in children with very few cases reported in the literature of children <12 years who had been reported as having isolated pulmonary LCH.

Case Report: 4-year-old unvaccinated Amish boy, otherwise healthy with no significant past medical history who presented with acute respiratory distress, found to have recurrent bilateral pneumothoraces status post bilateral chest tubes placement. Read More

Authors:  Dhangana Pinky,  Tadros Sameh

Keywords:  Langerhans cell histiocytosis

Park Halley,  Burgos Daylen Sire

Final Pr. ID: Poster #: CR-025

Pulmonary vein thrombosis is an exceedingly rare occurrence but should be considered in the differentials in evaluation for opacity seen on the chest radiograph, in a coagulopathic pediatric patient. Read More

Authors:  Park Halley,  Burgos Daylen Sire

Keywords:  Pulmonary vein thrombosis ,  coagulopathic ,  pulmonary embolism

W Mustapha Wan Irfan

Final Pr. ID: Poster #: CR-026

Horseshoe lung is a rare congenital anomaly and is mostly accompanied by scimitar syndrome. We reported a 3 months old baby girl was initially referred from the district hospital for ventilator support for severe congenital pneumonia and dextrocardia with features suggestive of elevated pulmonary artery pressure. She was born via emergency caesar for fetal distress with moderate meconium-stained liquor. Apgar's score was 5 in 1 minute and 9 in 5 minutes. She initially required non-invasive ventilation support and was able to wean to nasal prong on day 2 of life subsequently was intubated for worsening respiratory distress on day 8 of life and was transferred to our hospital. In our hospital, she was treated for nosocomial pneumonia and ventilated for 2 days and subsequently able to extubate to nasal prong. She completed a total of 2 courses of antibiotics within 2 weeks of life. Clinically patient is not dysmorphic but in respiratory distress with sub and intercostal recession. No chest deformity. Auscultation reduced air entry over the right lung, and no murmur was heard. Echo showed situs solitus with mesocardia, dominant RA/RV, AV/VA concordant, small PFO with intact IVS, tricuspid regurgitation 3 mmHg, dilated pulmonary artery and PDA 1.2 mm bidirectional predominantly right to left. Chest radiograph showed opacified right chest, dextrocardia and enlarged left hemithorax. CT Thorax showed a tiny right pulmonary artery, the right pulmonary vein is not clear, probably draining into the IVC- RA junction and a hypoplastic right lung suggestive of scimitar syndrome with horseshoe lung complicated with pulmonary hypertension. She was kept on nasal prong oxygen since extubated because of elevated pulmonary artery pressure and respiratory distress and was given sildenafil. Horseshoe lung is rare, and most of the reported cases share the same spectrum of cardiovascular anomalies identified in scimitar syndrome, and it can be confirmed by CT and angiography. Read More

Authors:  W Mustapha Wan Irfan

Keywords:  Scimitar syndrome ,  horsehoe lung ,  pulmonary hypertension