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Nutcracker syndrome is defined as left renal vein compression with concomitant clinical symptoms that include flank pain and hematuria. Historically, pediatric and adolescent patients with mild symptoms of nutcracker syndrome were simply observed while those with more severe symptoms underwent left renal vein transposition. Endovascular stenting of the left renal vein is a potentially efficacious and less invasive alternative for managing nutcracker syndrome in adolescents. The purpose of this study was to investigate the technical feasibility, efficacy and safety of left renal vein stenting in adolescents with nutcracker syndrome. We conducted a retrospective review of electronic medical records and imaging archives to identify adolescents undergoing endovascular stenting for nutcracker syndrome. We reviewed patient demographics including age, gender, presenting symptoms and diagnostic imaging findings. We compared pre- and post-stent deployment intravascular ultrasound (IVUS) and venography and evaluated patient symptoms in clinic up to 6 months following stent placement. Ten patients (average age 16 years, range 12–20 years) underwent 13 procedures. Initial symptoms included pain (n=10) and gross hematuria (n=5). Diagnostic imaging studies included CT abdomen pelvis (n=8), retroperitoneal US (n=6), MRI abdomen/pelvis (n=4), scrotal US (n=2), pelvic US (n=1) and renal Doppler US (n=2). Venography and IVUS demonstrated venous collaterals, proximal blanching at the left-renal-vein–IVC junction, pre-stenotic dilation and intraluminal compression. Most patients (n=9) experienced symptomatic resolution; however, three patients required reintervention to achieve asymptomatic status. No periprocedural complications occurred. In this carefully selected adolescent cohort, left renal vein stenting for nutcracker syndrome was often technically feasible, safe and effective in symptom management.

Nutcracker syndrome is defined as left renal vein compression with concomitant clinical symptoms that include flank pain and hematuria. Historically, pediatric and adolescent patients with mild symptoms of nutcracker syndrome were simply observed while those with more severe symptoms underwent left renal vein transposition. Endovascular stenting of the left renal vein is a potentially efficacious and less invasive alternative for managing nutcracker syndrome in adolescents.The purpose of this study was to investigate the technical feasibility, efficacy and safety of left renal vein stenting in adolescents with nutcracker syndrome.We conducted a retrospective review of electronic medical records and imaging archives to identify adolescents undergoing endovascular stenting for nutcracker syndrome. We reviewed patient demographics including age, gender, presenting symptoms and diagnostic imaging findings. We compared pre- and post-stent deployment intravascular ultrasound (IVUS) and venography and evaluated patient symptoms in clinic up to 6 months following stent placement.Ten patients (average age 16 years, range 12-20 years) underwent 13 procedures. Initial symptoms included pain (n=10) and gross hematuria (n=5). Diagnostic imaging studies included CT abdomen pelvis (n=8), retroperitoneal US (n=6), MRI abdomen/pelvis (n=4), scrotal US (n=2), pelvic US (n=1) and renal Doppler US (n=2). Venography and IVUS demonstrated venous collaterals, proximal blanching at the left-renal-vein-IVC junction, pre-stenotic dilation and intraluminal compression. Most patients (n=9) experienced symptomatic resolution; however, three patients required reintervention to achieve asymptomatic status. No periprocedural complications occurred.In this carefully selected adolescent cohort, left renal vein stenting for nutcracker syndrome was often technically feasible, safe and effective in symptom management.

The purpose of this study was to determine if patient age could accurately identify disrupted articular cartilage overlying an osteochondritis dissecans (OCD) lesion of the femoral condyle in adolescents. This could have important implications for imaging and treatment decisions.All patients from 2001 to 2014 who were arthroscopically treated for a femoral condyle OCD were included in this Institutional Review Board-approved study. Exclusion criteria were trochlear and patellar OCD lesions, idiopathic arthritis, and traumatic osteochondral injuries. Arthroscopy was performed to visualize and probe the articular surface. Arthroscopic and magnetic resonance imaging (MRI) findings were recorded as "intact" or "disrupted" cartilage. Extra-articular drilling was performed when the articular cartilage was intact.There were 119 patients (81 male, 68%) with 139 OCD lesions in 136 knees. The mean age at time of surgery was 13.0 years (range, 7.2 to 19.3 y). At arthroscopy, 115 knees had intact cartilage and 24 had disrupted cartilage. There was a significant difference in age between patients with intact versus disrupted cartilage at arthroscopy (12.5 vs. 15.3 y; P0.0001). Eighty-eight OCD lesions had MRIs preoperatively, showing 69 as intact and 19 (24%) disrupted. MRI reading for cartilage status had 94% sensitivity and 97% specificity. Multivariable regression analysis revealed that age (P0.01) and MRI status (P0.0001) were strong predictors of cartilage status. Sixteen years was the critical age in which both sensitivity was maximized and false positive probability was minimized. Over the age of 17 years, 7 of 7 (100%) had disrupted cartilage. Age alone was 100% sensitive for children below the age of 10, and 96% sensitive below the age of 13.Age was a good predictor of cartilage status in both younger (13 y) and older (≥17 y) patients in this study. For patients in the mid-range group (13 through 16 y), age alone is not an adequate predictor of cartilage status, but adding MRI increased accuracy.Age can be used to stratify patients and thereby influence diagnostic and treatment strategies.Level IV.

BACKGROUND: Delayed Gadolinium Enhanced Magnetic Resonance Imaging of Cartilage (dGEMRIC) was first introduced in 1996 by Bashir et al. as a method of indirectly evaluating glycosaminoglycan (GAG) changes in cartilage microstructure. Following publications originating from the Boston Children’s research group describing the association of early joint failure following periacetabular osteotomy (PAO) in patients with diminished preoperative cartilage T1 relaxation values, the interest in this imaging technique spread. dGEMRIC imaging was introduced into our clinical practice in 2013 with enrollment of both pediatric and adult patients. However, since the program’s apex in 2015, a marked decline in referral of adolescent patients for preoperative dGEMRIC imaging has occurred. Using data acquired during a quality analysis of the dGEMRIC program, this project was designed to investigate the utility of the dGEMRIC exam in our adolescent imaging cohort from 2013-2015 and to identify potential factors leading to decreased utilization from 2015-2018. METHODS: IRB approval was obtained for a HIPAA-compliant, retrospective cohort study which included all patients referred for dGEMRIC from May 2013- June 2015. 108 patients/112 exams/122 hips were identified. The study was designed in 4 parts including a. Blinded quantitative imaging review x 2 performed by 4 radiologists, b. Surgical review with 2 year post-operative follow-up completed July 2017, c. Patient phone interview, and d. Financial billing and reimbursement analysis. Subsequently, dGEMRIC utilization data from July 2015-May 2018 was compiled for comparative analysis of adolescent referral patterns. RESULTS: Of the 108 patients included in the comprehensive retrospective analysis, 56 were < 19 years of age with 43% of the adolescent patients participating in sports at time of presentation. 4 patients were excluded as the dGEMRIC data was either incomplete or could not be reprocessed. 61 hips were evaluated in the remaining 52 patients. The following summary data was compiled during the 4 part analysis. From the radiologist review: Siemens MapIt® T1 measurement software performed well at both 1.5 T and 3 T with good to excellent within rater ICC (0.79-0.92) but the between rater agreement was lacking particularly at 3.0 T (0.45) compared to 1.5 T (0.77) (p10 ($2300-$24,000). Following completion of the quality analysis and review of the results with the referring orthopedists, only 17 dGEMRIC exams have been performed in the adolescent age group in the subsequent 36 months. CONCLUSIONS: While the dGEMRIC exam holds promise as a prognosticating tool to guide surgical planning, in the adolescent practice environment, our historical data reveals that even when faced with abnormal T1 relaxation values, surgeons may opt to proceed with hip sparing surgical procedures simply because of the young age of the patient. From the radiologist’s perspective, dGEMRIC reporting is clouded by measurement variability. Inherent variability in the numbers reported brings to question the wisdom of using absolute T1 numeric thresholds to prognosticate joint failure risk. From the patient’s perspective, this imaging test comes with significant cost measured by time, pain, and financial burden. For all these reasons, utilization of this imaging study should be limited to the select few adolescent patients in whom documentation of an abnormal cartilage T1 value alone could substantially impact the surgical plan.

Overuse injuries of the shoulder and elbow are common in the skeletally immature throwing athlete. This review goes beyond describing the classic imaging findings of Little League shoulder and elbow and probes deeper into new insights suggesting a unifying etiology of metaphyseal or metaphyseal equivalent injury as the cause of many of the bony lesions described. Injury patterns change depending on the athlete's skeletal maturation, and the spectrum of abnormalities is reviewed.

This article is a compilation work authored by a pediatric radiologist, primary care pediatric sports medicine physician and pediatric orthopedic surgeon with the goal of providing a simplified diagnostic approach to the adolescent athlete presenting with shoulder pain. The spectrum of complex diagnoses often confused by innumerable radiologic acronyms can be distilled into common recognizable injury patterns. Once the physiology leading to the injury pattern is understood, the pediatric radiologist can perform a more focused imaging approach and provide a more meaningful interpretation to the referring orthopedic specialist.

Purpose To evaluate the technical feasibility and clinical efficacy of osteoid osteoma (OO) cryoablation in a large, pediatric/adolescent cohort. Materials and Methods An electronic medical record and imaging archive review was performed to identify all cryoablations performed for OOs between 2011 and 2015 at a single tertiary care pediatric hospital. The subsequent analysis included 29 patients with suspected OOs treated by cryoablation (age range, 3–18 y; mean age, 11.3 y; 17 boys; 12 girls). Conventional CT guidance was used in 22 procedures; cone-beam CT guidance was used in 7 procedures. Follow-up data were obtained via a standardized telephone questionnaire (23/29 patients; 79.3%) and clinical notes (5/29 patients; 17.2%). One patient was lost to follow-up. Results Technical success was achieved in 100% of patients (29/29). Immediate clinical success (cessation of pain and nonsteroidal antiinflammatory drug [NSAID] use within 1 mo after the procedure) was achieved in 27/28 patients (96.4%). Short-term clinical success (cessation of pain and NSAID use for > 3 mo after the procedure) was achieved in 24/25 patients (96%). Long-term clinical success (cessation of pain and NSAID use for > 12 mo after the procedure) was achieved in 19/21 patients (90.5%). Median pain scale score before the procedure was 10 (range, 5–10); median pain scale score after the procedure was 0 (range, 0–8; P Conclusion Image-guided cryoablation is a technically feasible, clinically efficacious therapeutic option for children and adolescents with symptomatic OO.

This study was designed to assess the effect of prenatal sonographic diagnosis on the treatment of congenital cystic adenomatoid malformation of the lung.The medical records of 27 patients with pathologically proven congenital cystic adenomatoid malformations were retrospectively reviewed. Patients were divided into four groups based on mode of presentation: with or without abnormal findings on prenatal sonography and with or without symptoms at birth. Age at diagnosis, age at surgical intervention, complications, and length of hospital stay were recorded for each group.Twenty-seven patients with 31 proven congenital cystic adenomatoid malformations were included. Eleven patients underwent prenatal sonography establishing the diagnosis (6 asymptomatic at birth, 5 symptomatic), and 16 did not have a prenatal diagnosis (10 asymptomatic at birth, 6 symptomatic). In the symptomatic populations, prenatal diagnosis had no impact on age at surgery, length of stay, or surgical complication rate (p = 0.78-0.83). In the asymptomatic population, prenatal diagnosis allowed early diagnosis (p0.001) and resection in the asymptomatic period. It was also associated with a shorter length of stay at the time of surgical resection (mean time, 4.2 days for patients with prenatal diagnosis versus 12.9 days for those without it;p0.001) and with a trend toward lower serious complication rate (3 patients without prenatal diagnosis versus 1 patient with it).Prenatal sonography provides the radiologist a means to identify congenital cystic adenomatoid malformations in a population of infants who are asymptomatic at birth. Surgical intervention in the asymptomatic infant is associated with a shorter length of stay, a trend toward fewer complications, and decreased medical cost compared with intervening after symptoms develop.

Although most traumatic abdominal injuries in children are treated with conservative nonsurgical management, traumatic perforation or infarction of the gastrointestinal tract still necessitates surgical management. It is imperative to recognize the often subtle computed tomographic (CT) findings of bowel or mesenteric trauma in children. Pediatric patients with bowel perforation or infarction due to trauma usually demonstrate multiple abnormalities at CT. A specific history of lap belt injury, bicycle handlebar injury, or child abuse with an abdominal injury should heighten suspicion for a bowel injury. CT findings in children with bowel or mesenteric trauma include free intraperitoneal air, free retroperitoneal air, extraluminal oral contrast material, free intraperitoneal fluid, bowel wall defect, bowel wall thickening, mesenteric stranding, fluid at the mesenteric root, focal hematoma, active hemorrhage, and mesenteric pseudoaneurysm. Some findings, such as free intraperitoneal air and focal bowel wall thickening, are associated with a strong likelihood of a bowel injury that requires surgical repair. Other findings, such as free intraperitoneal fluid, mesenteric stranding, fluid at the mesenteric root, and focal hematoma, are less specific for an injury that requires surgical repair. The hypoperfusion complex can usually be differentiated from a traumatic bowel injury; however, in some patients the imaging findings overlap.

Background/Purpose: Regression of a cystic adenomatoid malformation (CAM) in a fetus is well described. Little, however, is known about the postnatal course of these infants. This study attempts to correlate the prenatal course of CAMs with postnatal symptoms, radiological manifestations, and need for surgery. Methods: The clinical course of patients with a CAM diagnosed prenatally were retrospectively reviewed. Inclusion in the study required a prenatal ultrasound scan documenting a CAM. Results: Over 10 years, 14 patients with a CAM were diagnosed prenatally. Six (43%) showed a partial in utero regression. Four patients were symptomatic at birth and underwent a resection as newborns. Ten patients were asymptomatic at birth, and eight of these had normal chest x-rays. Elective resection has been performed in 3 of these 10, and two additional children are scheduled to undergo an excision near 1 year of age. The remaining five patients have undergone follow-up nonoperatively for a mean of 36 ± 15 months. Of the seven asymptomatic patients not undergoing immediate surgery, only one has shown a slight postnatal regression, despite five of these showing regression in utero. None have become symptomatic. Conclusions: The results suggest that regression of a CAM on prenatal ultrasound scan is common, but this process does not continue after birth. A normal chest x-ray does not indicate complete regression of a CAM; a computed tomography (CT) scan is required to evaluate such patients, and will generally demonstrate a CAM. Asymptomatic patients with a CAM may be followed up nonoperatively with no apparent adverse effects. The decision and timing of an excision in an asymptomatic patient remains controversial among pediatric surgeons.

Editor’s Note.—Everyone who has taken the course in radiologic pathology at the Armed Forces Institute of Pathology (AFIP) remembers bringing beautifully illustrated cases for accession to the Institute. In recent years, the staff of the Department of Radiologic Pathology has judged the “best cases” by organ system, and recognition is given to the winners on the last day of the class. With each issue of RadioGraphics, one or more of these cases are published, written by the winning resident. Radiologic-pathologic correlation is emphasized, and the causes of the imaging signs of various diseases are illustrated. Thomas M. Aquisto, MD ● Robert Yost, MD ● Kelley W. Marshall, MD

Development of a mycotic aneurysm or pseudoaneurysm after subacute bacterial endarteritis is uncommon. Nonetheless, patients with coarctation of the aorta are more likely to develop this complication. We describe a case of a large pseudoaneurysm discovered in a child with a previously undiagnosed aorta coarctation. Successful repair was performed with the aid of partial left heart bypass and the use of an interposition graft. A high index of suspicion is necessary to accurately diagnose this rare but life–threatening entity.

Rationale and Objectives. Residency selection committees expend substantial time and resources on assessing the quality of residency applicants to derive an appropriate rank order for the National Residency Matching Program. The authors determined whether there is a relationship between the rank number or rank percentile of applicants selected for a residency training program and subsequent radiology residency performance. Materials and Methods. Records of radiology residents completing their residency between 1991 and 1998 were reviewed. Available rank numbers and rank percentiles for each resident were compared with subsequent performance, as assessed subjectively by 4th-year radiology rotation evaluation forms and retrospective recall of four senior faculty members and objectively by numerical and percentile scores on the written portion of the American Board of Radiology (ABR) examinations. Correlation coefficients were obtained for each comparison. Results. Rank number and rank percentile were not significantly correlated with 4th-year resident rotation evaluations or ABR written examination scores or percentiles. A small correlation existed between rank order and retrospective evaluation of resident performance by the four senior faculty. Conclusion. Applicant rank number and rank percentile do not correlate with subsequent radiology residency performance as assessed on rotation evaluation forms or the ABR written examinations.