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OBJECTIVES: Our aim is to describe the radiologic characteristics of rib fractures in clinically diagnosed cases of child abuse and suggest a complementary imaging for radiographically occult injuries in highly suspicious cases of child abuse. METHODS: Retrospective analysis of initial and follow-up skeletal surveys and computed tomography (CT) scans of 16 patients younger than 12 months were reviewed after obtaining approval from our institutional review board. The number, location, displacement, and age of the rib fractures were recorded. RESULTS: Out of a total 105 rib fractures, 84% (87/105) were detected on the initial skeletal survey. Seventeen percent (18/105) were seen only after follow-up imaging, more than half of which (11/18) were detected on a subsequent CT. Majority of the fractures were posterior (43%) and anterior (30%) in location. An overwhelming majority (96%) of the fractures are nondisplaced. CONCLUSIONS: Seventeen percent of rib fractures analyzed in the study were not documented on the initial skeletal survey. Majority of fractures are nondisplaced and located posteriorly or anteriorly, areas that are often difficult to assess especially in the acute stage. The CT scan is more sensitive in evaluating these types of fractures. Low-dose chest CT can be an important imaging modality for suspicious cases of child abuse when initial radiographic findings are inconclusive. Language: en

Vomiting is a commonly reported symptom in infants less than three months of age. There are a multitude of pathologies to consider, both within and outside the gastrointestinal tract. In addition to conducting a thorough history and physical examination, a clinician formulates a reasonable differential diagnosis by consideration of two main factors: the infant's age and the characterization of the vomit as bilious or nonbilious. In this endeavor, the clinician is able to determine if an imaging study is needed and, if so, the urgency of the request. A review of the appropriate imaging evaluation of vomiting infants in the newborn to three-month-old age group is provided by organizing the discussion around the following three clinical scenarios: bilious vomiting, intermittent nonbilious vomiting since birth, and new-onset bilious vomiting. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every three years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

BACKGROUND AND OBJECTIVE:Children and adolescents with minor blunt head trauma and isolated skull fractures are often admitted to the hospital. The objective of this study was to describe the injury circumstances and frequency of clinically important neurologic complications among children with minor blunt head trauma and isolated linear skull fractures.METHODS:This study was a planned secondary analysis of a large prospective cohort study in children RESULTS:In the parent study, we enrolled 43 904 children (11 035 [25%] CONCLUSIONS:Children with minor blunt head trauma and isolated linear skull fractures are at very low risk of evolving other traumatic findings noted in subsequent imaging studies or requiring neurosurgical intervention. Hospital admission for neurologically normal children with isolated linear skull fractures after minor blunt head trauma for monitoring is typically unnecessary.

Intussusception is a common pediatric abdominal emergency, treated with image-guided reduction. Available techniques include fluoroscopic and ultrasonographic monitoring of liquid and air. The purpose of this study was to determine current practices and establish trends by comparing our findings with reports of previous surveys. This study is based on an e-mail survey sent to all 1,538 members of the Society for Pediatric Radiology. It included questions about demographics, presence of parents/surgeon during procedure, patient selection/preparation, use of sedation, preferred methods of reduction and technical details, approach to unsuccessful reduction, and self-reported incidence of success/perforation. The 456 respondents (30%) reported attempting 3,834 reductions in the preceding 12 months. Of these, 96% use fluoroscopy and 4% use US guidance for reduction; 78% use air, 20% prefer fluid; 75% require intravenous access; 63% expect a surgeon to be present in hospital; 93% do not sedate. Although inflating a rectal balloon is controversial, 39% do so, and 50% employ a pressure-release valve. Seventy-two percent attempt reductions three times in the same position. In case of unsuccessful reductions, 64% wait and re-attempt later, 19% apply manual pressure, and 15% try again in left decubitus position. About 20% reattempt reduction after waiting 2 h or more. By providing a better understanding of both trends in and diversity of current practice, we hope to increase the confidence with which the individual practitioner will approach each case.

Head trauma is a frequent indication for cranial imaging in children. CT is considered the first line of study for suspected intracranial injury because of its wide availability and rapid detection of acute hemorrhage. However, the majority of childhood head injuries occur without neurologic complications, and particular consideration should be given to the greater risks of ionizing radiation in young patients in the decision to use CT for those with mild head trauma. MRI can detect traumatic complications without radiation, but often requires sedation in children, owing to the examination length and motion sensitivity, which limits rapid assessment and exposes the patient to potential anesthesia risks. MRI may be helpful in patients with suspected nonaccidental trauma, with which axonal shear injury and ischemia are more common and documentation is critical, as well as in those whose clinical status is discordant with CT findings. Advanced techniques, such as diffusion tensor imaging, may identify changes occult by standard imaging, but data are currently insufficient to support routine clinical use. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Purpose The volume CT dose index (CTDI vol ) and the dose-length product, commonly reported for examinations performed on clinical CT scanners, should not be used as surrogates for patient dose. This is because significant under or overestimates of these actual values can occur when there is a mismatch between the actual body size of the patient and the 16 cm or 32 cm diameter CTDI vol phantoms. This mismatch can be exacerbated in pediatric body examinations because of the fact that some manufacturers use the large diameter phantom while other manufacturers use the small diameter phantom as the CTDI vol reference phantom. Method A clinical example is described for a pediatric patient with a 4-fold difference in CTDI vol between a presurgical CT examination and a postsurgical CT examination, even though the actual dose absorbed by the patient was about the same. Using methods published by the American Association of Physicists in Medicine, we calculated the size-specific dose estimate (SSDE), and compared the estimated measurement of dose using the SSDE with the CTDI vol . Results Using SSDE significantly reduced the discrepancy in radiation dose estimates of CTDI vol in the clinical study, and allowed dose estimate comparisons between scanners to be more meaningful. Conclusions Radiation dose estimates are more accurate when using the SSDE metric in lieu of the CTDI vol metric for reporting and comparing patient dose indices.

Although Wilms tumor is the most common renal malignancy in children, the differential diagnosis is extensive and includes both malignant and benign disorders. We present a simple mnemonic-WARM N COLD, to aid in remembering these diverse tumors. Imaging clues including age of the patient, associated disease or syndrome as well as salient imaging characteristics such as bilaterality, and type or presence of metastasis are also presented and can help differentiate between these renal tumors of childhood.

Prospective studies of infants at risk for autism spectrum disorder have provided important clues about the early behavioural symptoms of autism spectrum disorder. Diagnosis of autism spectrum disorder, however, is not currently made until at least 18 months of age. There is substantially less research on potential brain-based differences in the period between 6 and 12 months of age. Our objective in the current study was to use magnetic resonance imaging to identify any consistently observable brain anomalies in 6–9 month old infants who would later develop autism spectrum disorder. We conducted a prospective infant sibling study with longitudinal magnetic resonance imaging scans at three time points (6–9, 12–15, and 18–24 months of age), in conjunction with intensive behavioural assessments. Fifty-five infants (33 ‘high-risk’ infants having an older sibling with autism spectrum disorder and 22 ‘low-risk’ infants having no relatives with autism spectrum disorder) were imaged at 6–9 months; 43 of these (27 high-risk and 16 low-risk) were imaged at 12–15 months; and 42 (26 high-risk and 16 low-risk) were imaged again at 18–24 months. Infants were classified as meeting criteria for autism spectrum disorder, other developmental delays, or typical development at 24 months or later (mean age at outcome: 32.5 months). Compared with the other two groups, infants who developed autism spectrum disorder (n = 10) had significantly greater extra-axial fluid at 6–9 months, which persisted and remained elevated at 12–15 and 18–24 months. Extra-axial fluid is characterized by excessive cerebrospinal fluid in the subarachnoid space, particularly over the frontal lobes. The amount of extra-axial fluid detected as early as 6 months was predictive of more severe autism spectrum disorder symptoms at the time of outcome. Infants who developed autism spectrum disorder also had significantly larger total cerebral volumes at both 12–15 and 18–24 months of age. This is the first magnetic resonance imaging study to prospectively evaluate brain growth trajectories from infancy in children who develop autism spectrum disorder. The presence of excessive extra-axial fluid detected as early as 6 months and the lack of resolution by 24 months is a hitherto unreported brain anomaly in infants who later develop autism spectrum disorder. This is also the first magnetic resonance imaging evidence of brain enlargement in autism before age 2. These findings raise the potential for the use of structural magnetic resonance imaging to aid in the early detection of children at risk for autism spectrum disorder or other neurodevelopmental disorders.

Urinary tract infection (UTI) is common in young children and may cause pyelonephritis and renal scarring. Long-term complications from renal scarring are low. The role of imaging is to evaluate for underlying urologic abnormalities and guide treatment. In neonates there is increased risk for underlying urologic abnormalities. Evaluation for vesicoureteral reflux (VUR) may be appropriate especially in boys because of higher prevalence of VUR and to exclude posterior urethral valve. In children older than 2 months with first episode of uncomplicated UTI, there is no clear benefit of prophylactic antibiotic. Ultrasound is the only study that is usually appropriate. After the age of 6 years, UTIs are infrequent. There is no need for routine imaging as VUR is less common. In children with recurrent or complicated UTI, in addition to ultrasound, imaging of VUR is usually appropriate. Renal cortical scintigraphy may be appropriate in children with VUR, as renal scarring may support surgical intervention. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ObjectiveTo characterize regional differences in brain water distribution and content during diabetic ketoacidosis (DKA) in children and determine whether these differences correlate with regional vascular supply.Study designWe compared changes in brain water distribution and water content in different brain regions during DKA by analyzing magnetic resonance diffusion weighted imaging data collected during DKA and after recovery in 45 children (

Intussusception reduction allows young children to avoid surgery. However, graduating residents have had relatively little training in intussusception reduction and, for the most part, consider themselves ill-prepared to perform this procedure. The goal of this study was to assess the extent of training in intussusception reduction during one year of a pediatric radiology fellowship and to determine whether graduating fellows consider themselves adequately trained in this technique. Pediatric radiology fellows were surveyed during June 2010 and asked to characterize their fellowship, to indicate the number of intussusception reductions performed (both the total number and those performed with faculty oversight but without active faculty involvement), and to assess the adequacy of their training. There were 31 responses, representing almost 1/3 of current fellows. Pediatric radiology fellows perform on average 6.9 reductions, 3.8 of which are with faculty oversight but without active faculty involvement. Ninety percent consider themselves well-trained in the technique, whereas 10% are uncertain (none consider their training inadequate). Almost all pediatric radiology fellows consider their training in intussusception reduction to be adequate.

BACKGROUND: Men on active surveillance for clinical stage I nonseminomatous germ cell tumor (NSGCT) undergo frequent computed tomography imaging to avoid delayed detection of disease. Irradiation from frequent imaging and chemotherapy upon progression may place patients at increased risk of a second malignancy. In this study, the authors sought to identify such an increased risk among men who chose initial surveillance for NSGCT. METHODS: The authors utilized data from the Surveillance, Epidemiology and End Results Program and stratified the cohort based on whether they underwent retroperitoneal lymph node dissection (RPLND). A propensity-score model was used to adjust for covariates, and a competing-risks regression analysis was performed to estimate cumulative incidence rates of second malignancy. Incidence risk ratios were predicted by using the cumulative incidence rates per 10,000 patients. RESULTS: There was no statistically significant increase in the incidence of a secondary malignancy for the entire cohort of testicular cancer survivors. However, when the analysis was restricted to patients with clinical stage I NSGCT, nonsurgical management only in those aged >45 years was an independent predictor of developing a second malignancy. For every 10,000 patients with stage I NSGCT who chose to forego RPLND, an absolute excess incidence of 22, 52, and 73 secondary malignancies would be diagnosed at 5 years, 10 years, and 15 years, respectively. CONCLUSIONS: The current results indicated that patients aged >45 years who forego RPLND for T1 or T2 clinical stage I NSGCT are more likely to develop a second malignancy than those who do undergo RPLND. Nonsurgical management of NSGCT may be associated with more long-term health risks than primary RPLND. Cancer 2011;. © 2011 American Cancer Society.

Background Residents 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. Objective We sought to determine radiology residents’ exposure to intussusception reductions, and whether their experiences vary by region or institution. Materials and methods U.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. Results Six 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). Conclusion Radiology 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.

The most commonly encountered systemic thoracic venous anomaly is a persistent left superior vena cava that drains into the right atrium via the coronary sinus. A much rarer systemic venous anomaly is that of isolated anomalous drainage of a normally positioned right superior vena cava (RSVC) into the left atrium (LA). This has been reported in approximately 20 patients with the diagnosis usually being made by cardiac catheterization. We report the case of a toddler with asymptomatic hypoxemia resulting from anomalous drainage of a normal RSVC into his LA. This was diagnosed non-invasively by contrast-enhanced chest CT.

Symptomatic cerebral edema occurs in approximately 1% of children with diabetic ketoacidosis (DKA). However, asymptomatic or subclinical cerebral edema is thought to occur more frequently. Some small studies have found narrowing of the cerebral ventricles indicating cerebral edema in most or all children with DKA, but other studies have not detected narrowing in ventricle size. In this study, we measured the intercaudate width of the frontal horns of the lateral ventricles using magnetic resonance imaging (MRI) in children with DKA during treatment and after recovery from the DKA episode. We determined the frequency of ventricular narrowing and compared clinical and biochemical data for children with and without ventricular narrowing. Forty-one children completed the study protocol. The lateral ventricles were significantly smaller during DKA treatment (mean width, 9.3 +/- 0.3 vs. 10.2 +/- 0.3 mm after recovery from DKA, p < 0.001). Children with ventricular narrowing during DKA treatment (22 children, 54%) were more likely to have mental status abnormalities than those without narrowing [12/22 vs. 4/19 with Glasgow Coma Scale (GCS) scores below 15 during therapy, p = 0.03]. Multiple logistic regression analysis revealed that a lower initial PCO2 level was significantly associated with ventricular narrowing [odds ratio (OR) = 0.88, 95% confidence interval (95% CI) = 0.78-0.99, p = 0.047). No other variables analyzed were associated with ventricular narrowing in the multivariate analysis. We conclude that narrowing of the lateral ventricles is evident in just over half of children being treated for DKA. Although children with ventricular narrowing did not exhibit neurological abnormalities sufficient for a diagnosis of 'symptomatic cerebral edema', mild mental status abnormalities occurred frequently, suggesting that clinical evidence of cerebral edema in children with DKA may be more common than previously reported.

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.

Objectives Cerebral edema during diabetic ketoacidosis (DKA) has been attributed to osmotic cellular swelling during treatment. We evaluated cerebral water distribution and cerebral perfusion during DKA treatment in children. Study design We imaged 14 children during DKA treatment and after recovery, using both diffusion and perfusion weighted magnetic resonance imaging (MRI). We assessed the apparent diffusion coefficients (ADCs) and measures reflecting cerebral perfusion. Results The ADC was significantly elevated during DKA treatment (indicating increased water diffusion) in all regions except the occipital gray matter. Mean reductions in the ADC from initial to postrecovery MRI were: basal ganglia 4.7 ± 2.5 × 10 −5 mm 2 /s ( P =.002), thalamus 3.7 ± 2.8 × 10 −5 mm 2 /s, ( P =.002), periaqueductal gray matter 4.3 ± 5.1 × 10 −5 mm 2 /s ( P =.03), and frontal white matter 2.0 ± 3.1 × 10 −5 mm 2 /s ( P =.03). In contrast, the ADC in the occipital gray matter increased significantly from the initial to postrecovery MRI (mean increase 3.9 ± 3.9 × 10 −5 mm 2 /s, P =.004). Perfusion MRI during DKA treatment revealed significantly shorter mean transit times (MTTs) and higher peak tracer concentrations, possibly indicating increased cerebral blood flow (CBF). Conclusions Elevated ADC values during DKA treatment suggests a vasogenic process as the predominant mechanism of edema formation rather than osmotic cellular swelling.

Background. A history of loss of consciousness (LOC) is frequently used as an indication for cranial computed tomography (CT) in the emergency department (ED) evaluation of children with blunt head trauma.Objective. We sought to determine whether an isolated LOC and/or amnesia is predictive of traumatic brain injury (TBI) in children with blunt head trauma.Methods. We prospectively enrolled children 1 week, persistent neurologic deficits, or hospitalization for ≥2 nights. We then investigated the association of LOC and/or amnesia with TBI in those patients without other symptoms or signs of TBI (“isolated” LOC and/or amnesia).Results. Of eligible children, 2043 (77%) were enrolled, 1271 (62%) of whom underwent CT; 1159 (91%) of these 1271 had their LOC and/or amnesia status known. A total of 801 (39%) of the 2043 enrolled children had a documented history of LOC and/or amnesia. Of the 745 with documented LOC and/or amnesia who underwent CT, 70 (9.4%; 95% confidence interval [CI]: 7.4%, 11.7%) had TBI identified on CT versus 11 of 414 (2.7%; 95% CI: 1.3%, 4.7%) without LOC and/or amnesia (difference: 6.7%; 95% CI: 4.1%, 9.3%). Of the 801 children known to have had LOC and/or amnesia (regardless of whether they underwent CT), 77 (9.6%; 95% CI: 7.7%, 11.9%) had TBI requiring acute intervention versus 11 of 1115 (1%; 95% CI: 0.5%, 1.8%) of those without LOC and/or amnesia (difference: 8.6%; 95% CI: 6.5%, 10.7%). For those with an isolated LOC and/or amnesia without other signs or symptoms of TBI, however, 0 of 142 (95% CI: 0%, 2.1%) had TBI identified on CT, and 0 of 164 (95% CI: 0%,1.8%) had TBI requiring acute intervention.Conclusions. Isolated LOC and/or amnesia, defined by the absence of other clinical findings suggestive of TBI, are not predictive of either TBI on CT or TBI requiring acute intervention. Elimination of an isolated LOC and/or amnesia as an indication for CT may decrease unnecessary CT use in those patients without an appreciable risk of TBI.

Computed tomography (CT) is frequently used in evaluating children with blunt head trauma. Routine use of CT, however, has disadvantages. Therefore, we sought to derive a decision rule for identifying children at low risk for traumatic brain injuries.We enrolled children with blunt head trauma at a pediatric trauma center in an observational cohort study between July 1998 and September 2001. We evaluated clinical predictors of traumatic brain injury on CT scan and traumatic brain injury requiring acute intervention, defined by a neurosurgical procedure, antiepileptic medications for more than 1 week, persistent neurologic deficits, or hospitalization for at least 2 nights. We performed recursive partitioning to create clinical decision rules.Two thousand forty-three children were enrolled, 1,271 (62%) underwent CT, 98 (7.7%; 95% confidence interval [CI] 6.3% to 9.3%) had traumatic brain injuries on CT scan, and 105 (5.1%; 95% CI 4.2% to 6.2%) had traumatic brain injuries requiring acute intervention. Abnormal mental status, clinical signs of skull fracture, history of vomiting, scalp hematoma (in childrenor =2 years of age), or headache identified 97/98 (99%; 95% CI 94% to 100%) of those with traumatic brain injuries on CT scan and 105/105 (100%; 95% CI 97% to 100%) of those with traumatic brain injuries requiring acute intervention. Of the 304 (24%) children undergoing CT who had none of these predictors, only 1 (0.3%; 95% CI 0% to 1.8%) had traumatic brain injury on CT, and that patient was discharged from the ED without complications.Important factors for identifying children at low risk for traumatic brain injuries after blunt head trauma included the absence of: abnormal mental status, clinical signs of skull fracture, a history of vomiting, scalp hematoma (in childrenor =2 years of age), and headache.

Background: Blunt head trauma is a common cause of death and disability in children worldwide. Cranial computed tomography (CT), the reference standard for the diagnosis of traumatic brain injury (TBI), exposes children to ionizing radiation which has been linked to the development of brain tumors, leukemia, and other cancers. We describe the methods used to develop and test the effectiveness of a decision aid to facilitate shared decision-making with parents regarding whether to obtain a head CT scan or to further observe their child at home. Methods/Design: This is a protocol for a multicenter clinician-level parallel randomized trial to compare an intervention group receiving a decision aid, ‘Head CT Choice’, to a control group receiving usual care. The trial will be conducted at five diverse emergency departments (EDs) in Minnesota and California. Clinicians will be randomized to decision aid or usual care. Parents visiting the ED with children who are less than 18-years-old, have experienced blunt head trauma within 24 hours, and have one or two risk factors for clinically-important TBI (ciTBI) from the Pediatric Emergency Care Applied Research Network head injury clinical prediction rules will be eligible for enrollment. We will measure the effect of Head CT Choice on: (1) parent knowledge regarding their child’s risk of ciTBI, the available diagnostic options, and the risks of radiation exposure associated with a cranial CT scan (primary outcome); (2) parent engagement in the decision-making process; (3) the degree of conflict parents experience related to feeling uninformed; (4) patient and clinician satisfaction with the decision made; (5) the rate of ciTBI at seven days; (6) the proportion of patients in whom a cranial CT scan is obtained; and (7) seven-day healthcare utilization. To capture these outcomes, we will administer parent and clinician surveys immediately after each clinical encounter, obtain video recordings of parent-clinician discussions, administer parent healthcare utilization diaries, analyze hospital billing records, review the electronic medical record, and conduct telephone follow-up. Discussion: This multicenter trial will robustly assess the effectiveness of a decision aid on patient-centered outcomes, safety, and healthcare utilization in parents of children with minor head trauma in five diverse EDs. Trial registration: ClinicalTrials.gov registration number: NCT02063087. Registration date February 13, 2014.

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.

Background. Surveillance imaging of the brain and spinal neuraxis in patients with posterior fossa malignant tumors is commonly performed, with the assumption that early detection of tumor recurrence will improve outcome. However, the benefit of this imaging has not been proven.¶Purpose. To evaluate the usefulness of spinal surveillance imaging in children with nonmetastatic (at diagnosis, M0) posterior fossa ependymoma and medulloblastoma.¶Materials and methods. This retrospective study included 65 children (3 months to 16 years, mean 5.7 years) treated between 1985 and 1997 for ependymoma (22) and medulloblastoma (43). Medical records were reviewed for pathology and treatment data. Serial imaging of the head and spine was reviewed for evidence of tumor recurrence.¶Results. Twenty-four patients (37 %) had tumor recurrence, including 13 with ependymoma and 11 with medulloblastoma. Of the 17/24 recurrent patients initially diagnosed as M0 (6 medulloblastoma and 11 ependymoma), 13 (76 %) had a cranial recurrence only, and 4 (24 %) presented with concomitant cranial and spinal recurrence. No M0 patient presented solely with spinal metastases at recurrence.¶Conclusion. This study suggests that spinal surveillance imaging in patients with posterior fossa ependymoma or medulloblastoma initially staged as M0 may not be useful, as these patients initially recur intracranially. Thus, until an intracranial recurrence is detected, these patients may be spared the time, expense and sedation risk necessary for spinal imaging.

Intussusception resulting from osteosarcoma metastasis to the small bowel is a rare diagnosis. This case report describes a patient with this diagnosis, demonstrates the CT appearance of this lesion, and reviews the literature.

Skeletal surveys for non-accidental trauma (NAT) include lateral spinal and pelvic views, which have a significant radiation dose.To determine whether pelvic and lateral spinal radiographs should routinely be performed during initial bone surveys for suspected NAT.The radiology database was queried for the period May 2005 to May 2011 using CPT codes for skeletal surveys for suspected NAT. Studies performed for skeletal dysplasia and follow-up surveys were excluded. Initial skeletal surveys were reviewed to identify fractures present, including those identified only on lateral spinal and/or pelvic radiographs. Clinical information and MR imaging was reviewed for the single patient with vertebral compression deformities.Of the 530 children, 223 (42.1%) had rib and extremity fractures suspicious for NAT. No fractures were identified solely on pelvic radiographs. Only one child (0.2%) had vertebral compression deformities identified on a lateral spinal radiograph. This infant had rib and extremity fractures and was clinically paraplegic. MR imaging confirmed the vertebral body fractures.Since no fractures were identified solely on pelvic radiographs and on lateral spinal radiographs in children without evidence of NAT, nor in nearly all with evidence of NAT, inclusion of these views in the initial evaluation of children for suspected NAT may not be warranted.

Defining pathologic widening of the pubic symphysis in the pediatric population continues to be a clinical challenge. The purpose of this study is to define a normal range of pubic symphyseal widths in various age and gender groups using axial computerized tomography (CT) scans.Axial CT images of 140 patients aged between 2 years and 15 years were obtained from our database of preexisting scans. Using a commercially available software package, the single image with the narrowest pubic symphyseal width was identified and measured. Patients were further stratified based on gender and by age into three groups: group A (age 2-5 years), group B (age 6-11 years), and group C (age 12-15 years).The mean width ± 95% confidence interval for all cases was 4.59 mm ± 0.18 mm. The mean width for male and female patients was 4.86 mm ± 0.26 mm and 4.33 mm ± 0.24 mm, respectively. Based on the two-way analysis of variance, both age group and gender had a statistically significant effect. Post hoc testing demonstrated a statistically significant difference in mean symphyseal width between groups A and C (p0.0001) and groups B and C (p = 0.0025) but not between groups A and B (p = 0.055). When grouped by age, the mean male pubic symphyseal width was found to be 5.10 mm, 4.93 mm, and 4.45 mm, while the mean female width was found to be 4.94 mm, 4.33 mm, and 3.54 mm at 2 to 6 years, 7 to 11 years, and 12 to 15 years of age, respectively.In the pediatric population, males seem to have a wider pubic symphysis than females of the same age group. In both males and females, pubic symphyseal width decreases during the transition from infancy toward skeletal maturity.Epidemiologic study, level III.

Study objective We derive a prediction rule to identify children at very low risk for intra-abdominal injuries undergoing acute intervention and for whom computed tomography (CT) could be obviated. Methods We prospectively enrolled children with blunt torso trauma in 20 emergency departments. We used binary recursive partitioning to create a prediction rule to identify children at very low risk of intra-abdominal injuries undergoing acute intervention (therapeutic laparotomy, angiographic embolization, blood transfusion for abdominal hemorrhage, or intravenous fluid for ≥2 nights for pancreatic/gastrointestinal injuries). We considered only historical and physical examination variables with acceptable interrater reliability. Results We enrolled 12,044 children with a median age of 11.1 years (interquartile range 5.8, 15.1 years). Of the 761 (6.3%) children with intra-abdominal injuries, 203 (26.7%) received acute interventions. The prediction rule consisted of (in descending order of importance) no evidence of abdominal wall trauma or seat belt sign, Glasgow Coma Scale score greater than 13, no abdominal tenderness, no evidence of thoracic wall trauma, no complaints of abdominal pain, no decreased breath sounds, and no vomiting. The rule had a negative predictive value of 5,028 of 5,034 (99.9%; 95% confidence interval [CI] 99.7% to 100%), sensitivity of 197 of 203 (97%; 95% CI 94% to 99%), specificity of 5,028 of 11,841 (42.5%; 95% CI 41.6% to 43.4%), and negative likelihood ratio of 0.07 (95% CI 0.03 to 0.15). Conclusion A prediction rule consisting of 7 patient history and physical examination findings, and without laboratory or ultrasonographic information, identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention. These findings require external validation before implementation.

To describe the clinical presentations and outcomes of children with intraventricular hemorrhages (IVHs) after blunt head trauma (BHT).Subanalysis of a large, prospective, observational cohort study performed from June 1, 2004, through September 31, 2006.Twenty-five emergency departments participating in the Pediatric Emergency Care Applied Research Network. Patients Children presenting with IVH after BHT. Exposure Blunt head trauma.Clinical presentations and outcomes, including the Pediatric Overall Performance Category (POPC) and Pediatric Cerebral Performance Category (PCPC) scores at hospital discharge.Of 15 907 patients evaluated with computed tomography, 1156 (7.3%) had intracranial injuries. Forty-three of the 1156 (3.7%; 95% CI, 2.7%-5.0%) had nonisolated IVHs (ie, with intracranial injuries on computed tomography), and 10 of 1156 (0.9%; 95% CI, 0.4%-1.6%) had isolated IVHs. Only 4 of 43 (9.3%) of those with nonisolated IVHs had Glasgow Coma Scale (GCS) scores of 14 to 15, and all 10 (100.0%) with isolated IVHs had GCS scores of 15. No patients with isolated IVHs required neurosurgery or died. One patient had moderate overall disability (by the POPC score), and no patient had moderate or severe disability at discharge (by the PCPC score). Of the 43 patients with nonisolated IVHs, however, 16 (37.2%) died and 18 (41.9%) required neurosurgery. In 27 patients (62.8%), injuries ranged from moderate overall disability to brain death by the POPC score.Children with nonisolated IVHs after BHT typically present with GCS scores of less than 14, frequently require neurosurgery, and have high mortality rates. In contrast, those with isolated IVHs typically present with normal mental status and are at low risk for acute adverse events and poor outcomes.

This report describes a newborn with a cervical esophageal duplication cyst, a rare developmental anomaly of the neck. Only a few cases of this cystic entity have been described in the literature to date. This case is unique in that the patient had an air-fluid level within the lesion as a result of communication of the duplication cyst with the native esophagus.

Neuroblastoma is an enigmatic disease entity; some tumors disappear spontaneously without any therapy, while others progress with a fatal outcome despite the implementation of maximal modern therapy. However, strong prognostic factors can accurately predict whether children have "good" or "bad" disease at diagnosis, and the clinical stage is currently the most significant and clinically relevant prognostic factor. Therefore, for an individual patient, proper staging is of paramount importance for risk assessment and selection of optimal treatment. In 2009, the International Neuroblastoma Risk Group (INRG) Project proposed a new staging system designed for tumor staging before any treatment, including surgery. Compared with the focus of the International Neuroblastoma Staging System, which is currently the most used, the focus has now shifted from surgicopathologic findings to imaging findings. The new INRG Staging System includes two stages of localized disease, which are dependent on whether image-defined risk factors (IDRFs) are or are not present. IDRFs are features detected with imaging at the time of diagnosis. The present consensus report was written by the INRG Imaging Committee to optimize imaging and staging and reduce interobserver variability. The rationales for using imaging methods (ultrasonography, magnetic resonance imaging, computed tomography, and scintigraphy), as well as technical guidelines, are described. Definitions of the terms recommended for assessing IDRFs are provided with examples. It is anticipated that the use of standardized nomenclature will contribute substantially to more uniform staging and thereby facilitate comparisons of clinical trials conducted in different parts of the world.

Brainstem disconnection is a very rare neonatal abnormality, with only seven cases reported. We report a unique case of a neonate who presented at delivery with hypertonia, dysmorphic facial features, and respiratory distress, as well as numerous musculoskeletal and genitourinary abnormalities. MRI of the brain showed disconnection between the pons and medulla with cerebellar hypoplasia and absent cerebellar peduncles. It aided in the description of the neurological and vascular anomalies associated with this diagnosis.

CT imaging of head-injured children has risks of radiation-induced malignancy. Our aim was to identify children at very low risk of clinically-important traumatic brain injuries (ciTBI) for whom CT might be unnecessary.We enrolled patients younger than 18 years presenting within 24 h of head trauma with Glasgow Coma Scale scores of 14-15 in 25 North American emergency departments. We derived and validated age-specific prediction rules for ciTBI (death from traumatic brain injury, neurosurgery, intubation24 h, or hospital admissionor=2 nights).We enrolled and analysed 42 412 children (derivation and validation populations: 8502 and 2216 younger than 2 years, and 25 283 and 6411 aged 2 years and older). We obtained CT scans on 14 969 (35.3%); ciTBIs occurred in 376 (0.9%), and 60 (0.1%) underwent neurosurgery. In the validation population, the prediction rule for children younger than 2 years (normal mental status, no scalp haematoma except frontal, no loss of consciousness or loss of consciousness for less than 5 s, non-severe injury mechanism, no palpable skull fracture, and acting normally according to the parents) had a negative predictive value for ciTBI of 1176/1176 (100.0%, 95% CI 99.7-100 0) and sensitivity of 25/25 (100%, 86.3-100.0). 167 (24.1%) of 694 CT-imaged patients younger than 2 years were in this low-risk group. The prediction rule for children aged 2 years and older (normal mental status, no loss of consciousness, no vomiting, non-severe injury mechanism, no signs of basilar skull fracture, and no severe headache) had a negative predictive value of 3798/3800 (99.95%, 99.81-99.99) and sensitivity of 61/63 (96.8%, 89.0-99.6). 446 (20.1%) of 2223 CT-imaged patients aged 2 years and older were in this low-risk group. Neither rule missed neurosurgery in validation populations.These validated prediction rules identified children at very low risk of ciTBIs for whom CT can routinely be obviated.The Emergency Medical Services for Children Programme of the Maternal and Child Health Bureau, and the Maternal and Child Health Bureau Research Programme, Health Resources and Services Administration, US Department of Health and Human Services.

This article provides a review of the MR imaging features of the major primary malignant and benign bone tumors and tumorlike conditions encountered in the pediatric population. Malignant tumors discussed include osteosarcoma, Ewing sarcoma, chondrosarcoma, lymphoma, and malignant fibrous histiocytoma. Benign lesions discussed include simple bone cysts, aneurysmal bone cysts, giant cell tumor, osteochondroma, enchondroma, chondroblastoma, osteoid osteoma, osteoblastoma, nonossifying fibroma, fibrous dysplasia, osteofibrous dysplasia, hemangioma, and histiocytosis. The use of MR imaging in the diagnosis of these lesions is discussed, and the text is enhanced with imaging examples of the lesions.

To determine clinical and biochemical factors influencing cerebral edema formation during diabetic ketoacidosis (DKA) in children.We used magnetic resonance diffusion-weighted imaging to quantify edema formation. We measured the apparent diffusion coefficient (ADC) of brain water during and after DKA treatment in 26 children and correlated ADC changes with clinical and biochemical variables.Mean ADC values were elevated during DKA treatment compared with baseline (8.13 +/- 0.47 vs 7.74 +/- 0.49 x 10(-4) mm(2)/sec, difference in means 0.40, 95% CI: 0.25 to 0.55, P.001). Children with altered mental status during DKA had greater elevation in ADC. ADC elevation during DKA was positively correlated with initial serum urea nitrogen concentration (correlation coefficient 0.41, P = .03) and initial respiratory rate (correlation coefficient 0.61, P.001). ADC elevation was not significantly correlated with initial serum glucose, sodium or effective osmolality, nor with changes in glucose, sodium or osmolality during treatment. Multivariable analyses identified the initial urea nitrogen concentration and respiratory rate as independently associated with ADC elevation.The degree of edema formation during DKA in children is correlated with the degree of dehydration and hyperventilation at presentation, but not with factors related to initial osmolality or osmotic changes during treatment. These data support the hypothesis that CE is related to cerebral hypoperfusion during DKA, and that osmotic fluctuations during DKA treatment do not play a primary causal role.

Type 1 diabetes mellitus (DM) affects about 1 in 500 children and can cause damage to multiple organ systems. In recent years, growing attention has been given to the effects of type 1 DM on the brain. In this article we review important imaging features of the brain in children with type 1 DM, including (1) imaging the child in diabetic ketoacidosis and the child with hypoglycemia, (2) syndromes associated with type 1 DM, and (3) long-term effects of type 1 DM on brain structure.

We compare test characteristics of abdominal computed tomography (CT) with and without oral contrast for identifying intra-abdominal injuries.This was a planned subanalysis of a prospective, multicenter study of children (18 years) with blunt torso trauma. Children imaged in the emergency department with abdominal CT using intravenous contrast were eligible. Oral contrast use was based on the participating centers' guidelines and discretions. Clinical courses were followed to identify patients with intra-abdominal injuries. Abdominal CTs were considered positive for intra-abdominal injury if a specific intra-abdominal injury was identified and considered abnormal if any findings suggestive of intra-abdominal injury were identified on the CT.A total of 12,044 patients were enrolled, with 5,276 undergoing abdominal CT with intravenous contrast. Of the 4,987 CTs (95%) with documented use or nonuse of oral contrast, 1,010 (20%) were with and 3,977 (80%) were without oral contrast; 686 patients (14%) had intra-abdominal injuries, including 127 CTs (19%) with and 559 (81%) without oral contrast. The sensitivity in the detection of any intra-abdominal injury in the oral contrast versus no oral contrast groups was sensitivitycontrast 99.2% (95% confidence interval [CI] 95.7% to 100.0%) versus sensitivityno contrast 97.7% (95% CI 96.1% to 98.8%), difference 1.5% (95% CI -0.4% to 3.5%). The specificity of the oral contrast versus no oral contrast groups was specificitycontrast 84.7% (95% CI 82.2% to 87.0%) versus specificityno contrast 80.8% (95% CI 79.4% to 82.1%), difference 4.0% (95% CI 1.3% to 6.7%).Oral contrast is still used in a substantial portion of children undergoing abdominal CT after blunt torso trauma. With the exception of a slightly better specificity, test characteristics for detecting intra-abdominal injury were similar between CT with and without oral contrast.

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.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.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).While this study group is small, these findings suggest that CT is better than CXR in visualizing rib fractures in abused infants.

OBJECTIVE. Our objective was to report three delayed, generalized, and protracted cutaneous reactions in two patients that are compatible with acute generalized exanthematous pustulosis (AGEP) after contrast medium administration.CONCLUSION. Radiologists and referring clinicians need to be aware of late adverse reactions to the administration of contrast media and to distinguish these from other possible causes.

Paraneoplastic limbic encephalitis (PLE) is an unusual disorder that is characterized by the association of clinical limbic system abnormalities with neoplasia, usually malignancy. It has rarely been reported in children and then manifests during the teenage years. Diagnosis is often delayed, especially when the tumor has not been recognized. In adults, the diagnosis can be revealed by the presence of antineuronal antibodies. We describe an unusual case of behavioral disturbance leading rapidly to coma in a 14-year-old girl with CSF pleocytosis who was found 10 weeks later to have an immature ovarian teratoma. Although her symptoms eventually improved slightly after tumor excision, she died while in rehabilitation. PLE is an important diagnosis to consider in the teenage girl with symptoms of a progressive limbic disorder and CSF pleocytosis, and whose brain MR imaging demonstrates no abnormality or mild T2-weighted temporal lobe signal abnormality. When this constellation of findings presents in a teenage girl, the possibility of an underlying ovarian teratoma should be considered.

To determine size-dependent technique factors for pediatric computed tomography (CT) by using physically measured objective data.Six phantom cylinders (10-32 cm in diameter) were scanned with a clinical multi-detector row CT scanner. CT noise was statistically characterized for CT technique factors from 80 to 140 kVp and from 10 to 300 mAs. Dose measurements were performed with each phantom. Dilute iodine and tissue contrast were determined with computer calculations validated with measured data. The dose, noise, and contrast data were computer fit, and pediatric CT technique factors (milliampere seconds) necessary to maintain the contrast-to-noise ratio (CNR) were computed.As compared with that in a reference cylindric adult abdomen of 28 cm in diameter, CNR was maintained at a constant level in pediatric patients of 25, 20, and 15 cm in diameter, respectively, when milliampere second values of 0.557, 0.196, and 0.054 of the adult milliampere second values were used. The corresponding doses were reduced to 0.642, 0.287, and 0.090 of the 28-cm-diameter adult dose, respectively. CT techniques for examination of pediatric heads measuring 15 and 13 cm, respectively, can involve the use of milliampere second values of 0.572 and 0.366 of those used for examination of a standard 17-cm-diameter adult head.CT technique charts for pediatric abdominal and head examinations were produced on the basis of physically measured data; use of these tables will enable pediatric radiation dose to be reduced while CNR is preserved.

Diplopodia, or duplicated foot, is a rare congenital anomaly. It differs from polydactyly in that supernumerary metatarsal and tarsal bones are present as well as extra digits. Only a few cases of this anomaly have been reported in the literature to date. We present a newborn male without intrauterine teratogen exposure who was born with a duplicate foot of the left lower extremity and imperforate anus.

Renal cell carcinoma (RCC) is rare in children and comprises only 1–3% of all pediatric primary renal tumors. Recently, several case reports have described RCC developing in patients previously treated for advanced stage neuroblastoma (NB). Our experience with four patients treated for advanced stage NB during early childhood who developed RCC later in life are added to 14 others in the literature. These patients and our review of the literature suggest an association between RCC and NB that warrants further study.

Granulocytic sarcoma is an unusual manifestation of acute myelogenous leukemia in children and presents a diagnostic dilemma when it precedes the development of systemic disease. We present CT and MRI findings of an extraconal mass proven to be granulocytic sarcoma in a 6-year-old otherwise healthy boy with several months' history of worsening unilateral proptosis. This case is unique in providing exquisite CT and MRI correlation and in demonstrating rapid response to therapy. Further, as cytogenetics were positive for the t(8,21) translocation, this case provides opportunity for discussion of the associated incidence of this translocation and concomitant better prognosis.

Summary: Isolated sulfite oxidase deficiency is a rare autosomal inherited disorder of the normal degradation of sulfur-containing amino acids. Premature death in infancy secondary to severe neurologic deterioration is the usual outcome. This article provides an analysis, in temporal form, of brain imaging findings in this disorder.