13 Can't-Miss Findings on Pediatric Imaging Studies

Jose Luiz de Oliveira Schiavon, MD | December 2, 2015

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When interpreting pediatric imaging studies, it is critical to be familiar with normal variations,
anatomic deviations, normal bone appearance, growth plate maturation, as well as pitfalls related
to different imaging artifacts, in order to identify abnormal findings. See if you can correctly
determine any findings on the following pediatric images.
The computed tomography (CT) scan shown reveals an acute subdural hematoma with midline
shift in a child who suffered physical abuse.
Image courtesy of Lawrence R. Ricci, MD.
http://reference.medscape.com/features/slideshow/ci-pedi#page=1

An unresponsive preschooler was brought to the emergency department with an unclear trauma
history. Fluid attenuated inversion recovery (FLAIR) magnetic resonance imaging (MRI) of the
brain was performed (shown).
What are the MRI findings and their possible causes?
Image courtesy of Medscape.

Findings: Intrahemispheric subarachnoid bleeding (red arrows) with bilateral subdural

hematomas (blue arrows) are present.
Child abuse should be suspected in trauma cases with a missing or unclear history, particularly
with high-risk children. Those considered to be at high risk include infants and preschoolers, as
well as children with behavioral problems, developmental delays, physical and/or mental
abnormalities, or other medical conditions. A skeletal survey should be requested whenever child
abuse is suspected.[1]
Image courtesy of Medscape.

A child presented with a slap mark on the face, raising the concern for possible abuse. A skeletal
survey was requested. Radiographs showed old radius and ulna fractures (yellow arrows).
Every year, more than 3 million reports of child abuse and neglect are made in the United States,
involving more than 6 million children.[2] A study estimated that the lifetime cost of one year of
confirmed cases of child maltreatment in the United States was $124 billion.[3,4]
Image courtesy of Lawrence R. Ricci, MD.

The skeletal survey of the same child in the previous slide also revealed multiple rib fractures
(yellow arrows). Fractures that are highly specific for abuse include posterior rib fractures,
scapular, and spinous process fractures. Fractures with different healing stages also have high
specificity for abuse. These findings should mandate reporting to child protective services.
An average of four children per day die as a result of child abuse or neglect in the United States.
[5]
In 2013, an estimated 1520 children died as a consequence of child abuse or neglect.[5]
Image courtesy of Lawrence R. Ricci, MD.

Question: What is the syndrome revealed in the MRI shown? What is the role of MRI in this
syndrome?
Image courtesy of Medscape.

Answer: Tethered cord syndrome

The MRI reveals a low-lying conus below the level of L2 (red arrow), which is associated with
anatomic abnormalities such as an intradural sacral lipoma/tethered cord (blue arrow). In these
types of cases, MRI may aid in surgical decision making.[6]
Image courtesy of Medscape.

Shown, is an abdominal CT scan of a child with blunt abdominal trauma history. What is the
most common diagnosis based on the CT scan and its history?
Image courtesy of Medscape.

Answer: Pancreatic pseudocyst

The CT scan in the region of the pancreas demonstrates a large, well-marginated cystic structure
that is a pancreatic pseudocyst. The differential diagnosis includes a large choledochal cyst. The
pseudocyst, a fibrous-walled cavity filled with pancreatic enzymes that complicates pancreatitis,
is primarily localized in the lesser sac behind the stomach. The incidence of pancreatic
pseudocysts is greater than 50% when associated with traumatic injury to the abdomen. As a
result of limited case reporting and underdiagnosis by clinicians, the frequency and true
incidence of pancreatitis in children is unknown. Trauma is responsible for an estimated 10%40% of pediatric cases of acute pancreatitis.[6,7]
Image courtesy of Medscape.

This CT scan shows a large type I choledochal cyst and the adjacent gallbladder. Note that the
cyst is typically filled with bile, which produces waterlike attenuation. If any question
concerning the diagnosis remains after a CT scan, endoscopic retrograde
cholangiopancreatography (ERCP) can be performed.
Image courtesy of Medscape.

This technetium-99m pertechnetate scan was performed on a 12-year-old boy with right lower
abdominal pain and rectal bleeding. Neither appendicitis nor intussusception was found on
ultrasonography. What is the diagnosis?
Image courtesy of Medscape.

Answer: Meckel diverticulum

The delayed image shows focal activity in the right lower quadrant. An inflamed Meckel
diverticulum containing ectopic gastric mucosa was removed during surgery.
Image courtesy of Medscape.

This CT scan was obtained on a child with right lower abdominal pain. There were no abnormal
ultrasonographic findings due to intestinal interposition. What does the CT scan reveal?
Image courtesy of Medscape/Mark V Mazziotti, MD.

Answer: A distended, ovoid structure descending into the pelvis and containing a central, round
calcification (appendicolith) (arrow)
Acute appendicitis is one of the most common causes of abdominal pain, and it is the most
frequent condition leading to emergency abdominal surgery in children. A delay in the diagnosis
is associated with rupture and other complications, especially in young children.
Ultrasonography is often the first imaging modality used in pregnant and pediatric patients with
abdominal pain. Its advantages include lack of radiation exposure and short acquisition time, as
well as the potential to identify and diagnose other causes of abdominal pain. A significant
disadvantage of ultrasonography is that it is operator dependent, and its diagnostic potential
relies on the skill of the operator.
Image courtesy of Medscape/Mark V Mazziotti, MD.

A child presented with recurrent urinary tract infections. The ultrasound was performed as
recommended. The first study demonstrated bilateral hydronephrosis with thinning of the renal
parenchyma (shown). What diagnoses should be considered?
Image courtesy of Medscape.

Answer: Renal cysts and/or hydronephrosis

This longitudinal sonogram of the right kidney shows that the hypoechoic areas interconnect
(arrow), a finding that is consistent with hydronephrosis rather than with multiple distinct renal
cysts, which do not interconnect. What imaging study is indicated next?
Image courtesy of Medscape.

Answer: Voiding cystourethrogram

The ultrasound findings may be due to complications of a posterior urethral valve. Voiding
cystourethrographic evaluation of the abdomen, bladder, and urethra confirmed the presence of
the posterior urethral valve (left) as well as demonstrated a trabeculated bladder, diverticula, and
bilateral massive reflux (right).
Images courtesy of Medscape.

This angiogram was performed on a 10-year-old girl with headaches. What are the indications,
findings, and diagnosis suggested by this image?
Image courtesy of Robert Cirillo, MD.

Indication: More than 50% of patients who present with headache, blood pressure differences in
the extremities, claudication, arthralgia, and/or bruit (most commonly at the carotid artery) have
arteritis of the great vessels.[8]
Findings: Narrowing of the proximal descending aorta (blue arrow) and right brachiocephalic
artery (red arrow) are present.
Diagnosis: Takayasu arteritis is the only form of aortitis that causes stenosis and occlusion of the
aorta. Fibromuscular dysplasia is a differential diagnosis for Takayasu arteritis.[9] However,
fibromuscular dysplasia usually does not affect the aorta, as evidenced by this angiography, and
it is rare in the subclavian artery. Ninety percent of patients with Takayasu arteritis are younger
than 30 years,[9] and most of them are female.[10]
Image courtesy of Robert Cirillo, MD.

This frontal chest radiograph is from a newborn presenting early respiratory distress. What are
the findings and diagnosis suggested by this image?
Image courtesy of Medscape.

Findings: Herniation of the liver (white arrow) and bowel loops into the right hemithorax
(yellow arrow) as well as a shift of the heart and mediastinum to the left side (green arrow) can
be seen on the radiograph.
Diagnosis: This is a right-sided congenital diaphragmatic hernia. Loss of the normal welldelineated right superior curvilinear diaphragmatic contour (black arrow) and the shifted
mediastinum help to distinguish this condition from others in the differential diagnosis, such as
congenital cystic adenomatoid malformation.
Image courtesy of Medscape.

This chest radiograph is from another newborn presenting early respiratory distress. What are the
findings that would lead to the correct diagnosis?
Image courtesy of Medscape.

Findings: Physiologic fluid was reabsorbed from an area of congenital cystic adenomatoid
malformation and replaced with an air-containing cystic area that occupies the right upper lung
(yellow arrow). Note the well-defined right diaphragmatic line that helps to distinguish this
finding from herniation (black arrow).
Diagnosis: Congenital cystic adenomatoid malformation is a developmental hamartomatous
abnormality of the lung, with adenomatoid proliferation of cysts resembling bronchioles.[11]
Image courtesy of Medscape.

A child was presented with a 2-month history of wheezing. What is the main finding on this
radiograph?
Image courtesy of Medscape/Brit B. Gay, Jr, MD.

This radiograph obtained during an exhale is from the same child as in the previous slide. Note
the continued hyperlucency and hyperexpansion of the right hemithorax that was also present in
slide 24. A greater mediastinal shift is noted toward the left lung field. What is the most likely
diagnosis based on these findings?
Image courtesy of Medscape/Brit B. Gay, Jr, MD.

Answer: Foreign body aspiration

This radiograph is from another child with the same clinical condition as the child in the previous
two slides. It shows a radiopaque earring backing (arrow) lodged in the right mainstem
bronchus. Aspirated foreign bodies are most often found in pediatric patients, and they account
for thousands of US emergency department visits annually.[11] Clinicians must therefore maintain
a high index of suspicion for airway foreign body aspiration in young patients to allow prompt
treatment as well as to avoid its complications. Estimates of deaths from foreign body aspiration
range from hundreds to thousands,[11-13] with most deaths occurring before hospital evaluation and
treatment.[13]
The most common site of airway foreign bodies is the right mainstem bronchus due to its
posterior location, shallow angle to the trachea, and wide diameter. The density of the aspirated
item will determine whether or not it can be directly identified on radiographs. Indirect signs of
airway foreign body used to confirm the diagnosis include ipsilateral focal overinflation if there
is partial obstruction or ipsilateral atelectasis if a more complete obstruction is present.[13] The
patient in slides 24 and 25 had a corn kernel removed from their right mainstem bronchus during
bronchoscopy.
Image courtesy of Medscape.

This radiograph is from an infant with abdominal pain and vomiting. What should be suspected?
Image courtesy of Medscape/ Kelly Marshall, MD, Scottish Rite Hospital, Children's Healthcare
of Atlanta.

Note the small bowel obstruction pattern, with crescent sign to the left upper quadrant; these
findings should always indicate the diagnosis of intussusception. Unfortunately, in plain
abdominal radiography, up to 40% of cases have no signs that suggest this diagnosis, which can
also be evaluated by the ultrasound.[14]
Image courtesy of Medscape/ Kelly Marshall, MD, Scottish Rite Hospital, Children's Healthcare
of Atlanta.

This ultrasound reveals the classic target sign of an intussusception case. The ultrasound has
almost 98% of sensitivity and specificity for this important diagnosis that should be treated
immediately by therapeutic enema or surgical reduction.[15,16]
Image courtesy of Medscape.
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