Pediatric Imaging:

10/09/2012
Pediatric Imaging:
Cases from the Emergency
Department
E. Mann
Hospital for Sick Children,
Toronto, Canada
Conflict of Interest
I have no commercial or financial interests
related to the subject matter of this
presentation.
Objectives
• Review several common and a few
unusual pediatric emergency
presentations.
• Discuss differential diagnoses and
highlight important findings to reach
most likely diagnosis.
Case 1
•
•
•
•
•
17 day old neonate
Palpable deformity of the scalp
Not regressing
Firm on palpation
Prolonged delivery
• Mass does not cross
beyond the sagittal
suture line (blue
arrow)
• Soft tissue periosteal
elevation (yellow arrow)
• No skull fracture
• Sharply demarcated soft
tissue density parietal
Mirror image artifact
can be confusing
regarding underlying
brain and possible
epidural process
1
10/09/2012
Later presentation – same
diagnosis
• Continuity of the outer periosteum with
peripheral calcification (yellow arrow)
• No true internal vascularity
Outer border may
calcify as a rim
Sag – Parietal
Cor – Parietal
Caput Succedaneum
Differential diagnoses
1. Caput succedaneum
2. Subgaleal hemorrhage
3. Cephalohematoma
4. Soft tissue tumour NYD
Subgaleal hemorrhage
• Occurs immediately after vaginal delivery
Subcutaneous hemorrhage requiring no
intervention
• Typically not imaged – clinical diagnosis
• Not limited by suture lines
• Typically soft puffy swelling
• May be associated with discoloration/
bruising
• Heals spontaneously within a few days
Subgaleal hemorrhage
• Bleeding into the subaponeurotic space
from rupture of emissary veins
• Crosses suture lines
• Covers a larger area typically compared
with cephalohematoma
• Potentially life-threatening
• Associated with vacuum assisted delivery
2
10/09/2012
Cephalohematoma
•
•
•
•
•
Soft tissue periosteal elevation
No skull fracture
Sharply demarcated soft tissue density
Mass does not cross suture line
Continuity of the outer periosteum with
peripheral calcification
• Outer border may calcify as a rim
• May take many months to regress
Soft tissue
tumour
• Many prenatally
diagnosed
• Variable
presentations
depending on type
of tumour
• Hemangioma in this
case with flow voids,
vascular tumour and
phleboliths
Ultrasound Right Neck
Case 2
• Subcutaneous
•
•
•
•
•
3 month old with torticollis
Palpable mass in neck
Noticed shortly after birth
Gradual increase in size
No skin discoloration
• Echogenic
• Heterogeneous
• No calcification
• Lobulated welldefined, soft
tissue mass
Yellow arrow:
SCM muscle
Blue arrow:
lobulated
margins
Internal vascularity
No vascular tangle
Echogenicity similar
to fat
Yellow arrow:
SCM muscle
T1-weighted MR
• Defined, lobulated
subcutaneous
lesion
• No flow voids/
large vessels
• Fat tissue within
• Heterogeneous
intermediate to low
T1 SI tissue/
fibrous septa
3
10/09/2012
T1 W MR
T1 W MR +FS
T1 W FS + Gad
• Fat globules suppress
• No fat enhancement
• Periphery and septations enhance
Differential diagnoses
• Subcutaneous fat necrosis
• Lipoblastoma
• Fibromatosis colli
• Infantile fibrosarcoma
Subcutaneous Fat Necrosis
• Usually history of difficult delivery
• Firm palpable masses appear days to weeks
after birth
• Can have increased vascularity
• Moderately well-defined margins
• Lobulated, hypoechoic areas
• Can be complicated by hypercalcemia –
nephrocalcinosis/ nephrolithiasis
Echogenic, lobulated, subcutaneous fat
Normal contralateral subcutaneous tissues
4
10/09/2012
Lipoblastoma
• Typically subcutaneous, well-defined
• Variable soft tissue and mature fat
• Can be indistinguishable from a lipoma or
liposarcoma
• Immature and fibrous components are low
T1, high T2 SI and enhance
• Macroscopic fat does not enhance
• Usually < 3 years of age at presentation
Fibromatosis Colli
• Benign manifestation of infantile fibromatosis
• Mass-like fusiform enlargement of the
sternocleidomastoid muscle
• Ipsilateral torticollis
• Can be associated with shoulder dystocia
• Proximal and distal muscle fibers extend into
the lesion
• Mildly hypervascular
• No calcifications or cystic areas
Fibromatosis
Colli
Infantile Fibrosarcoma
•
•
•
•
•
Solitary, rapidly enlarging firm mass
Frequently involves a striated muscle
May have areas of hemorrhage or necrosis
Vascular
Relatively homogeneous mass with equal to
minimal increased T1 signal intensity
compared to muscle
• Increased T2 signal intensity compared to
both muscle and fat
• Avidly enhances post gadolinium
5
10/09/2012
Infantile Fibrosarcoma of the SCM
T1 W MR
Case 3
• 18 month old
• 1 month of neck pain and
decreased ROM
• No trauma
• Head tilt
• No fever
• Destructive lesion
involving C4 vertebral
body with vertebra plana
• Fracture/ dislocation of
right C4 lamina
• Permeative appearance
of the right sided
posterior elements
T1 W MR + Gad
• Flattening of the
C4 vertebral body
• Permeative bone
• Displacement of
C3/4 at the
spinolaminar line
• Straightening of
physiologic
lordosis
• Prominent anterior
soft tissues
• Expansile, exophytic, soft tissue involving the right
lateral process, pedicle and lamina of the C4
vertebral body
• Displaces the right vertebral artery
• Soft tissue component
anterior to the vertebral
body
• Mild indentation of the
thecal sac at T4
6
10/09/2012
Diffuse metastatic disease
Differential diagnoses
• Metastatic disease
• Langerhans Cell Histiocytosis (EG)
• Fracture
• Osteomyelitis
• Neuroblastoma metastases
• Leukemic involvement
• Other childhood primary lesions with
invasion
• Sclerotic margins not usually a feature of
metastatic disease
Langerhans Cell Histiocytosis
•
•
•
•
•
•
Beveled edges of the lytic skull lesions
Lytic lesions with geographic margins
Unifocal or multifocal osteolysis +/- path #s
Not typically confluent
Associated bone edema
Lesions enhance
Bone scan: lesions may be hot or cold
Radiolucent areas with
endosteal erosion (+/periosteal reaction)
Vertebra plana
7
10/09/2012
Differential Diagnosis of
Vertebra Plana
“FETISH”
F – Fracture
E – EG (Langerhans’)
T – Tumour (mets eg. NBL or other)
I – Infection
S – Steroid Use
H - Hemangioma
Case 4
•
•
•
•
•
•
•
•
5 year old boy
Right flank pain
Fever
Possible renal mass on outside
ultrasound
Right kidney lesion
Ill-defined, echogenic region within kidney
Relatively reduced perfusion
Some mass effect
No cystic region or calcification
Mid-pole lesion
Normal parenchyma
upper pole
8
10/09/2012
Differential diagnoses
• Acute pyonephrosis
• Mesoblastic nephroma
• Renal abscess
• Focal pyelonephritis
Acute pyonephrosis - PUV
• Debris within the dilated
collection systems
• Perinephric fluid
• Bilateral process
• Echogenic parenchyma
• Hydronephrosis
Acute pyonephrosis
• Infected, obstructed urinary tract
• May be due to UPJO, stone or
potentially bladder outlet (PUV)
• Requires decompression
• Potential need for nephrostomy tube,
depending on level of obstruction
Acute pyonephrosis - PUV
•
•
•
•
Bladder trabeculation
Circumferentially thick wall
Dilated posterior urethra
Small caliber anterior urethra
on VCUG
Mesoblastic Nephroma
• Commonly found in the neonatal period
(less than 3 months of age)
• Hamartomatous lesion
• Commonly mimics Wilm’s tumour
• No malignant potential
• Usually a large, non-tender mass at
presentation
• Can be heterogeneous if hemorrhage or
necrosis
Mesoblastic
Nephroma
9
10/09/2012
Mesoblastic Nephroma
STIR
T1
T1 FS + Gad
Early abscess formation – fluid
component, avascular
Renal Abscess
•
•
•
•
Well defined region
Avascular component with necrosis
Progress from focal pyelonephritis
+/- Perinephric fluid
Further
necrosis,
abscess
Focal Pyelonephritis
•
•
•
•
Pseudo-mass with ill-defined margins
Indistinct cortical-medullary differentiation
No cystic change within region
Renal size discrepancy may be greater
than 1 cm
• Focal area with relatively reduced
vascularity
• +/- Perinephric fluid
• Can lead to focal renal scarring
10
10/09/2012
Case 5
•
•
•
•
•
Rapid onset scrotal swelling
Very painful to touch
Reddish discoloration
Bilateral
Afebrile
Fountain-like,
striated
appearance of
edema and
hypervascularity
Marked,
homogeneous
thickening of the
scrotal wall – skin and
subcutaneous tissues
Differential Diagnoses
•
•
•
•
Acute Idiopathic Scrotal Edema
•
•
•
•
•
Erythema and swelling of the scrotum
Usually bilateral, may be asymmetric
More common in children than adults
Ultrasound is diagnostic
Increased blood flow in the scrotal soft
tissues and on colour Doppler – “fountain
sign”
• Not associated with dysuria – self limiting
Acute idiopathic scrotal edema
Testicular torsion
Leukemic infiltration
Appendix testis torsion
Acute Testicular Torsion
• True surgical emergency
• Often in peripubertal boys, young adults
• Often associated with reactive hydrocele
and thickening of scrotal skin
(surrounding regions may be hyperemic)
11
10/09/2012
Acute Testicular Torsion
• If the grey scale appearance is normal,
testis is likely viable
• Abnormal echotexture may indicate
edema/infarction
• Twisted cord can be seen as a
heterogeneous mass superior to the
testis (torsion knot)
• Absent or decreased vascularity relative
to normal side
RIGHT
Similar size and
echogenicity
R
L
Different
vascularity R>L
Torsion knot –
twisted
spermatic cord
cranial to testis
• Neonatal torsion
• Difficulty in interpreting
Doppler
• Bilateral hydroceles
• Inhomogeneous left
testicle
RIGHT
LEFT
LEFT
Leukemic Infiltration of Testes
• Enlarged, hypoechoic testicles
• Asymmetric, may be heterogeneous
texture
• May have associated slightly red
scrotum (hyperemia)
• Hypervascular on Doppler exam
• Clinical history of leukemia (ALL, etc.)
Left testicle : 3.1 X 2.1 X 1.7 cm
Right testicle: 1.6 X 1.1 X 0.9 cm
12
10/09/2012
Torsion of the Appendix Testis
Midline scrotum transverse
• Diminished or avascular hypoechoic mass
typically near the epididymal head
• May have reactive hyperemia of the
epididymis and testis
• May have associated hydrocele
• Self limiting
• Unilateral
Case 6
•
•
•
•
Fall on outstretched hand
Elbow pain
Limited range of motion
Assess for fracture
CRITOL
Capitellum
Radius
Internal (medial) epicondyle
Trochlea
Olecranon
Lateral epicondyle
O
I
L
T
C
R
13
10/09/2012
Medial epicondyle avulsion
Differential Diagnoses
•
•
•
•
Medial epicondyle avulsion
Supracondylar fracture
Monteggia fracture
Lateral condyle fracture
• Intra-articular displacement of avulsed
medial epicondyle
• Pseudo trochlea ossification center
Supracondylar Fracture
Most common elbow fracture in children
Effusions
around the
joint elevate
fat pads,
raise concern
for intraarticular
fracture
Monteggia Fracture
• Fracture ulna –
dislocation radial head
• Orthogonal views to
assess radius –
capitellum relationship
Lateral Condyle Fracture
• Oblique views may best demonstrate
• Fracture cleft may not be apparent initially
• Suspect intra-articular fracture due to effusion
Thanks for your
attention!
14
10/09/2012
Suggested Reading
Suggested Reading
• Mangurten HH. Birth injuries. In: Fanaroff AA, Martin FJ eds.
Neonatal-Perinatal Medicine: Diseases of the Fetus and Infant. 9th
ed. Philadelphia, Pa: Mosby Elsevier; 2010.
• Kan JH, Kleinman PK, Gebhardt MC, Kocher MS. Pediatric and
Adolescent Musculoskeletal MRI – A Case-Based Approach. New
York: Springer; 2007.
• George HL, Unnikrishnan PN, James LA et al. Lipoblastoma – an
unfamiliar but important diagnosis. A case series and literature
review. Acta Orthop Belg 2009; 75: 533-536.
• Srinath G, Cohen M. Imaging findings in subcutaneous fat necrosis
in a newborn. Pediatr Radiol 2006; 36: 361-363.
• Vasireddy S, Long SD, Sacheti B, Mayforth RD. MRI and US
findings of subcutaneous fat necrosis of the newborn. Pediatr Radiol
2009; 39: 73-76.
• Azouz EM, Saigal G, Rodriguez MM, Podda A. Langerhans’ cell
histiocytosis: pathology, imaging and treatment of skeletal
involvement. Pediatr Radiol 2005, 35(2): 103-115.
• Ilyas M, Mastin ST, Richard GA. Age-related radiological imaging in
children with acute pyelonephritis. Pediatr Nephrol 2002, 17(1):3034.
• Subcommittee on Urinary Tract Infection; Steering Committee on
Quality Improvement and Management. Urinary Tract Infection:
Clinical Practice Guideline for the Diagnosis and Management of the
Initial UTI in Febrile Infants and Children 2 to 24 Months. Pediatrics.
August 28, 2011.
• Lee A, Park SJ, Lee HK et al. Acute idiopathic scrotal edema:
ultrasonographic findings at an emergency unit. Eur Radiol 2009;
29:2075-2080.
Suggested Reading
• Aso C, Enriquez G, Fite M, et al. Gray-Scale and Color Doppler
Sonography of Scrotal Disorders in Children: An Update.
Radiographics 2005; 25:1197-1214.
• Yerkes EB, Robertson FM, Gitlin J et al. Management of Perinatal
Torsion: Today, Tomorrow or Never? J Urol 2005; 174:1579-1583.
• Geiger J, Epelman M, Darge K. The Fountain Sign. A novel Color
Doppler Sonographic Finding for the Diagnosis of Acute Idiopathic
Scrotal Edema. J Ultrasound Med 2010; 29(8):1233-1237.
15