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A 15-year-old male with transposition of the great arteries presented with exertional chest pain. He was found to have a circumflex coronary artery from the neo-pulmonary artery that had not been transferred during his arterial switch operation. The circumflex coronary artery, fed through collaterals from a re-implanted single coronary artery, resulted in coronary steal. This report describes a management pathway to treat this rare anomaly., (© 2014 Wiley Periodicals, Inc.)

Aggressive cardiac revascularization requires recognition of stunned and hibernating myocardium, and cost considerations may well govern the technique used. Dynamic low-dose (1 mCi) [123I]iodophenylpentadecanoic acid (IPPA) metabolic imaging is a potential alternative to PET using either 18FDG or 15O-water. Resting IPPA images were obtained from patients with severe ischemic cardiomyopathy, and transmural myocardial biopsies were obtained during coronary bypass surgery to confirm viability. Thirty-nine of 43 (91%) biopsies confirmed the results of the IPPA images with a sensitivity for viability of 33/36 (92%) and a specificity of 6/7 (86%). Postoperatively, wall motion improved in 80% of IPPA-viable, dysfunctional segments. Furthermore, when compared to reinjection thallium (SPECT-TI) scans after myocardial infarction, IPPA-SPECT-TI concordance occurred in 27/35 (77%) (K = 0.536, p = 0.0003). Similar to PET, IPPA demonstrated more viability than SPECT-TI, 26/35 (74%) versus 18/35 (51%) (p = 0.047). Metabolic IPPA cardiac viability imaging is a safe, inexpensive technique that may be a useful alternative to PET.

Clearance of the radiopharmaceutical Tc-99m DTPA estimated from blood samples with no urine collection can provide a reliable estimate of glomerular filtration rate (GFR) in adults, but has not been well studied in children. The disposition of Tc-99m DTPA was determined in 17 children with cancer, and the influence of binding and study design on the estimates for serum clearance were evaluated. Nine blood samples were obtained over 6 hours in each patient, and serum was assayed for total and free Tc-99m. Free Tc-99m DTPA was determined by ultrafiltration. Estimates of clearance derived from a two-compartment model for ultrafiltrable Tc-99m DTPA were determined from all nine measured concentrations, and these results served as a reference value for GFR in each subject. Total Tc-99m DTPA concentrations also were best described by a two-compartment model, but the median total clearance (35 ml/min) was significantly (p < 0.01) lower than the ultrafiltrate clearance (58 ml/min). The effect of a simplified sampling schedule was assessed from clearance estimates based on a 3-point subset of the ultrafiltrable data. The median clearance of 69 ml/minute was significantly higher (p < 0.01) than the reference GFR. However with a correction factor included to account for the positive bias arising from the limited sampling schedule, the reference estimates for GFR were well predicted (r2 = 0.99) with no significant bias. Ultrafiltrable Tc-99m DTPA serum clearance using a limited sampling schedule can provide a consistent and clinically feasible estimate of glomerular filtration rate in children, but binding in serum and study design are potentially important confounding factors.

Objective: The null hypothesis is that active labor is a more important factor with regard to both timing and progression of periventricular-intraventricular hemorrhage than is route of delivery. Infants delivered by cesarean section after entering the active phase of labor will behave in a manner similar to that of previously studied infants delivered vaginally as to when periventricular-intraventricular hemorrhage occurs and frequency of progression., Study Design: The 106 infants of 85 women delivered by cesarean section were the subjects of this study. Forty-six infants were in the no-labor group, 33 in the latent-phase labor group, and 27 in the active-phase labor group. Head ultrasonographic examinations were performed at delivery, at 1, 6, 12, and 24 hours, and then daily for the first 7 days of life. Continuous variables were compared by one-way analysis of variance among those infants with no hemorrhage or with periventricular-intraventricular hemorrhage. Categoric variables were compared by chi 2 analysis and Fisher's exact test when appropriate. A p value of less than 0.05 was considered significant., Results: There was no difference in the frequency of early hemorrhage (less than or equal to 1 hour of age), late hemorrhage (greater than 1 hour of age), or overall periventricular-intraventricular hemorrhage in the infants not in labor, in latent-phase labor, or in active-phase labor at the time of cesarean section. However, the frequency of grade 3 or 4 hemorrhage and the progression of hemorrhage were significantly higher in the infants whose mothers had an active phase of labor compared with infants whose mothers had no labor or did not progress beyond the latent phase. Infants who had early periventricular-intraventricular hemorrhage (less than or equal to 1 hour of age) also had a higher frequency of progression of hemorrhage., Conclusions: Cesarean section before the active phase of labor does not change the overall frequency of hemorrhage but results in a lower frequency of progression to grade 3 or 4 hemorrhage. We do not feel that these data support performing more cesarean sections for preterm delivery as a method of preventing progression of periventricular-intraventricular hemorrhage in the preterm infant.

The scintigraphic appearance of an overuse injury at the insertion of the iliotibial band is described. This injury was depicted on three-phase bone scintigraphy as focally increased radionuclide concentration in the anterolateral tibial condyle (lateral tibial tubercle) where the iliotibial band inserts. Overuse injuries involving the insertion of the iliotibial band are uncommon and are not to be confused with a stress fracture or other bony lesion involving the lateral tibial condyle.

While avid accumulation of gallium-67 citrate and technetium-99m methylene diphosphonate (MDP) occurs initially in most cases of primary Ewing sarcoma, uptake after therapy is less well defined. Thirty patients with Ewing sarcoma who underwent Ga-67 and bone scintigraphy at diagnosis, at completion of therapy, and at relapse from 1978 to 1988 were evaluated. All 30 patients showed less primary site Ga-67 activity following therapy. Twenty-three of 28 patients who underwent corresponding bone scintigraphy showed less uptake, but residual activity was usually more intense than with Ga-67. Avid reaccumulation of Ga-67 occurred in four of five patients with primary site relapse, while patients who underwent bone scintigraphy showed less change. It was concluded that a greater decrease in Ga-67 than in Tc-99m MDP uptake often occurs in patients successfully treated for primary Ewing sarcoma. Information obtained at Ga-67 scintigraphy is most likely to be helpful if results of bone scintigraphy remain abnormal or if occult relapse is suspected.

Bedside microcomputer-derived, minute-to-minute mean arterial pressure (MAP) values during the first 48 hours of life were studied in 100 preterm babies with birth weight less than or equal to 1500 gm. In those babies (n = 72) with no periventricular-intraventricular hemorrhage (PV-IVH) or with grade 1 PV-IVH, the MAP values increased during the study period, with minute-to-minute variation and interval undulation. The MAP values in those with birth weight greater than 1000 gm were higher than in those of lower birth weight. Infants in whom grades 2 to 4 PV-IVH developed (n = 28) had consistently lower MAP values during the study period. Minute-to-minute variability, expressed as the average of the coefficients of variation at 15-minute intervals, did not differ between birth weight groups, nor did they differ between the PV-IVH group and their matched control subjects. However, those with PV-IVH spent a greater percentage of time, with a coefficient of variation greater than or equal to 13% or less than 3%, than their matched control subjects spent (p less than 0.005). This study provides reference data for MAP changes in premature babies. The observed MAP changes in those with PV-IVH lend support to a significant role for MAP alterations in the pathogenesis of PV-IVH.

Dipyridamole TI-201 imaging is an ideal alternative to exercise TI-201 scintigraphy in patients who are unwilling or unable to perform maximum exercise stress. The use of intravenous dipyridamole, alone or in combination with exercise, has not been approved for clinical practice by the Food and Drug Administration. Once approval is granted, the test will become a widely used and important component of the cardiac work-up. The indications, methodology, side effects, and utility of dipyridamole cardiac imaging in the clinical setting are discussed and a variety of examples presented.

The association between periventricular-intraventricular hemorrhage (PV-IVH) and frequent handling resulting from various neonatal intensive care procedures and routine interventions was evaluated in a prospective clinical study. Inborn premature babies with birth weight less than or equal to 1500 gm (n = 156) who did not have PV-IVH or who had grade 1 PV-IVH at less than or equal to 1 hour were randomly assigned to the reduced manipulation protocol (n = 62) or to standard care (n = 94). A bedside microcomputer-based data acquisition system was used to monitor the duration of rest or the number of interventions per day. Infants assigned to receive reduced manipulation spent a significantly higher percentage of time each day at rest than did those who received standard manipulation (p less than 0.006). However, the incidence of grades 2 to 4 PV-IVH did not differ significantly (30% in the study vs 37% in the standard manipulation group). When we analyzed the effect of manipulation in relation to risk of PV-IVH, while taking into account other perinatal variables, standard manipulation was not associated with increased risk of grades 2 to 4 PV-IVH. However, low birth weight, maternal smoking, general anesthesia, early grade 1 PV-IVH, low hematocrit, lowest arterial oxygen pressure within the first 6 hours of life, and large base deficit at 6 hours of age all increased the relative risk of grades 2 to 4 PV-IVH.

Hypophosphatasia, a rare heritable form of rickets/osteomalacia, is characterized by deficient activity of the tissue nonspecific (liver/bone/kidney) isoenzyme of alkaline phosphatase (ALP). Signs may be present prenatally or not until late adult life. Although the infantile form of hypophosphatasia has usually been categorized as an autosomal recessive (AR) disorder, several studies suggest that childhood cases are the consequence of either AR or autosomal dominant (AD) inheritance and adult cases are primarily AD. Eastman and Bixler (J Craniofac Genet Dev Biol 3:213-234, 1983) propose that all cases of hypophosphatasia may reflect AD inheritance with 85% penetrance and homozygous lethality. We report on 3 patients with hypophosphatasia in a black family, first manifested clinically during infancy, where the pattern of inheritance for each is consistent with AR transmission. Two were brothers who died from the disorder. The other patient, a cousin, presented with classic stigmata of hypophosphatasia during infancy, but is now age 5 1/2 years and has had a much milder clinical course. Although consanguinity is absent, the maternal grandmothers are sibs as are the maternal grandfathers and the paternal grandmothers. The family history is otherwise negative for skeletal or dental disease. Laboratory and radiographic results are consistent with heterozygosity in each parent. Fibroblast ALP activity is less than 1% normal in all 3 patients with no complementation observed in heterokaryon analysis. Accordingly, the genetic defects appear to be identical in all 3 patients. Our findings show that infantile hypophosphatasia may be inherited as an AR condition where there is variable expressivity and that homozygosity or compound heterozygosity, as may be the case in this family, is not necessarily lethal.

The blood pressure (BP) and transcutaneous PO2 (TcPO2) changes associated with intensive care procedures were evaluated to determine whether responses differ between babies with and without periventricular-intraventricular hemorrhage (PV-IVH). Fifty-three inborn babies less than or equal to 1500 g were studied using a microcomputer-based monitoring system. With almost any procedure including a seemingly benign one such as a diaper change, peak systolic BP increased and TcPO2 decreased. However, responses to interventions did not differ between babies with PV-IVH and those without PV-IVH. Neither did these responses differ between those with birth weight less than or equal to 1000 g and greater than 1000 g. When each baby's record was scanned for the highest peak systolic BP before diagnosis of PV-IVH or within 48 hours in those with no PV-IVH and their BP points plotted against birth weight, a stable region was evident wherein PV-IVH occurred at a lower incidence (13%). When peak systolic BP was beyond this stable region, the incidence of PV-IVH was significantly higher, 70% (P less than .0001). The stability boundary for the maximum systolic BP is birth weight-dependent; the limit for the highest tolerable peak systolic BP is lower for the low-birth-weight infant. In over 70% of instances the highest peak systolic BP was associated with motor activities either induced by nursery procedures or spontaneous. We speculate that decreasing the frequency of intensive care interventions may decrease episodic BP increases to levels beyond the birth weight-dependent stability boundary where PV-IVH is likely to occur.

Variation in skin-to-kidney center distance has been shown to have a significant influence on quantification of renal function with the gamma camera. Several techniques to compensate for this variability have been proposed in adults, yet it has been suggested that depth correction is not necessary for quantitative renography in children. Skin-to-kidney center distances were measured from computed tomograms in 53 supine pediatric patients. Nearly 40% of the kidneys examined varied more than 1 cm from the average renal depth, and 8% deviated more than 2 cm. Right kidney depth differed from left kidney depth by more than 1 cm in less than 10% of the patients. Measurements were in agreement with regression equations based on lateral scintigraphy in children, but were consistently underestimated by nomograms developed for skin-to-kidney center distance in adults. Failure to recognize interindividual variability in skin-to-kidney center distance can introduce significant errors in quantitative pediatric renography.

The radiologic, CT, MR, and histological features of a case of chondrosarcoma of the femur presenting in childhood are reported. This case emphasizes the use of correlative imaging in establishing the diagnosis as well as the value of MR supplemented by Gadolinium-DTPA enhancement in disclosing abundant necrosis within the tumor.

Symptomatic urinary tract infection (UTI) in childhood is estimated to occur with a frequency of up to 3% through adolescence. The practitioner caring for children requires both anatomic and physiologic information concerning the urinary tract to assist in diagnosis, treatment, and prognosis. Advances in diagnostic imaging have resulted in numerous methods for evaluation of the urinary system. These procedures differ in the type of information obtained, risk or discomfort to the patient, and cost. Selection of the proper test(s) requires an understanding of these factors. Based on our survey of recent pertinent literature and our clinical experience, we present guidelines for appropriate diagnostic imaging in children with UTI, and we discuss the benefits and limitations of available imaging techniques along with concepts regarding the pathogenesis of UTI and causes of renal damage from UTI.

The purpose of this prospective study was to evaluate the effects of the active phase of labor and route of delivery on the frequency of germinal layer/intraventricular hemorrhage in 89 infants with ultrasound-estimated fetal weights less than or equal to 1750 gm. Twenty-eight infants (31.5%) had germinal layer/intraventricular hemorrhage within 1 hour after birth and an additional 15 infants (17%) had germinal layer/intraventricular hemorrhage beyond 1 hour after birth. Infants with germinal layer/intraventricular hemorrhage had a significantly lower gestational age (p less than 0.003) and birth weight (p less than 0.007). Germinal layer/intraventricular hemorrhage within 1 hour after delivery was increased in the infants of women who experienced the active phase of labor regardless of the route of delivery. However, the incidence of germinal layer/intraventricular hemorrhage beyond 1 hour after delivery and the overall incidence were similar in the vaginal delivery and cesarean delivery groups. In addition, there was an increased incidence of progression to grades III and IV hemorrhage regardless of route of delivery in the infants whose mothers experienced the active phase of labor.

One hundred fifty-five inborn infants with a birth weight less than or equal to 1,500 gm were prospectively evaluated for germinal layer/intraventricular hemorrhage. Maternal characteristics, obstetric factors, and neonatal condition in the immediate newborn period were analyzed as possible risk factors for germinal layer/intraventricular hemorrhage. Early germinal layer/intraventricular hemorrhage or hemorrhages identified during the first 24 hours of life were observed in 85 (55%) of these infants. Another 37 (24%) had germinal layer/intraventricular hemorrhage after 24 hours of age (late germinal layer/intraventricular hemorrhage). None of the maternal and obstetric variables, including labor, mode of delivery, and presentation, appeared to increase the risk of germinal layer/intraventricular hemorrhage. The immediate neonatal condition, birth weight, gestational age, and intrauterine growth, all influenced the occurrence of germinal layer/intraventricular hemorrhage, especially early germinal layer/intraventricular hemorrhage. We suggest that future studies to investigate the role of maternal or obstetric factors in the pathogenesis of germinal layer/intraventricular hemorrhage should discriminate early from late germinal layer/intraventricular hemorrhage. Obstetric factors are more likely to influence the early onset of germinal layer/intraventricular hemorrhage; their effect, if any, becomes less discernible later.

A case is reported in whom there was a unilateral complete arrest of differentiation of the otocyst associated with an ipsilateral mild hemifacial hypoplasia and auricular abnormalities. The patient's tympanic membrane and VII nerve function were normal and a normal ossicular mass was identified on CT Scan. This case illustrates that development of the middle ear cavity (exclusive of structures on the medial wall), external ear canal and VII nerve can be independent of development of the inner ear and that a unilateral absence of otic capsule differentiation can take place without severe associated abnormalities.

A case of ileal dysgenesis in a child presenting with anemia and chronic growth suppression, and characterized preoperatively with duodenal barium infusion and technetium pertechnetate scan is discussed.

After a 3-month course of weekly intravenous infusions of pooled normal plasma in an attempt at enzyme replacement therapy, we observed gradual and prolonged normalization of circulating alkaline phosphatase (AP) activity in a boy with infantile hypophosphatasia. During this 4-month period, when hypophosphatasemia had been corrected, electrophoretic and heat denaturation studies suggested that the AP in serum was skeletal in origin. Serial radiographic and histologic studies of bone demonstrated skeletal remineralization and the appearance of AP activity in osteoblasts and chondrocytes after the infusions. Considerable clinical improvement coincided with the skeletal remineralization. Our observations indicate that in one patient with infantile hypophosphatasia the structural gene for the tissue-nonspecific (bone/liver/kidney) AP isoenzyme was intact and could be expressed with marked physiologic effect. Infantile hypophosphatasia may result from absence or inactivation of a circulating factor(s) that regulates the expression of the gene for tissue nonspecific AP.

The Hyper IgE syndrome is a rare disease consisting of recurrent sinusitis and pneumonia, pneumatoceles, chronic dermatitis, and elevated serum levels of IgE. The primary radiographic abnormalities are recurrent alveolar lung disease and pneumatoceles. Pneumothorax may occasionally occur as in one of our cases. Other causes of pneumatoceles are usually easily excluded by the history and other clinical data. Pulmonary scintigraphy and computed tomography may add information valuable to the management of these patients.

Two cases of unsuccessful hydrostatic reduction of intussusception are reported. Both were associated with barium filling multiple loops of distal ileum, despite lack of complete reduction of the intussusception. The presence of free ileal reflux does not guarantee successful reduction. Careful examination of the cecum for residual intussusceptum and of non-contrast-filled small-bowel loops for evidence of remaining small-bowel obstruction is essential to recognize unsuccessful reduction.

Intraarterial digital subtraction angiography (IA-DSA) was performed in 80 pediatric patients. Forty-four underwent arterial injections with digital filming techniques. Of the 130 injections, DSA imaging was good or excellent in 121, often allowing resolution of vessels 1 mm in size. Thirty-six of the 80 patients underwent cardiac evaluation with intra-cardiac injections. Improved contrast resolution with IA-DSA allowed the use of smaller catheters (3-4F) and smaller amounts of contrast material. Immediate availability of subtracted images (no film processing delay) resulted in shorter total procedure time. Outpatient studies are possible. IA-DSA provides several notable advantages for the pediatric patient.

It has been implied that the recognition of fat in a renal tumor suggests that the lesion is benign. Several authors have suggested tht angiomyolipoma is the only common renal tumor containing mature adipose tissue. Other neoplasms may contain mature fat that can be identified with current diagnostic imaging techniques. Under discussion is our experience with Wilms' tumor containing a predominance of adipose tissue.

After biochemical and radiographic studies, enzyme replacement therapy in three patients with the infantile form of hypophosphatasia was attempted by weekly intravenous infusions of bone alkaline phosphatase-rich (BAP) plasma from patients with Paget bone disease. Subsequently, circulating BAP activity was substantially increased in each patient, and in one was maintained in the normal range for nearly 2 months. Despite partial or complete correction of the deficiency of circulating BAP activity, we observed no radiographic evidence for arrest of progressive osteopenia or improvement in rachitic defects in any of the patients. Failure of infants with hypophosphatasia to show significant healing of rickets on correction of circulating BAP activity supports the hypothesis that this isoenzyme functions in situ during normal skeletal mineralization.

Infantile and adult type polycystic kidney diseases are 2 disparate genetic disorders and generally are easily distinguishable on the basis of clinical, pathologic, and radiologic findings. We present 3 children with infantile polycystic kidney disease, ages 9 months to 6 years, in whom the excretory urogram and/or renal ultrasound or gross anatomical appearance of the kidneys resembled adult polycystic kidney disease. The findings from these 3 patients emphasize the importance of renal and liver biopsies in the diagnosis of cystic kidney disease in young children.

Perforation of the duodenum is an uncommon, but serious complication which may occur in children with dermatomyositis. In this disease vasculitis may involve the bowel to a variable extent and result in radiologic manifestations of intestinal injury ranging from benign pneumatosis intestinalis to signs of bowel perforation. We report two children with dermatomyositis in whom perforation of the second portion of the duodenum occurred. This serious complication should be considered in any child with dermatomyositis when extraluminal gas is suspected on abdominal radiographs.

A child with urine ascites as a delayed manifestation of post-traumatic intraperitoneal bladder rupture is presented. The diagnosis was suggested by abdominal CT scan and confirmed with a cystogram. While uncommon, late presentation of intraperitoneal bladder rupture following trauma may occur from masking of a primary laceration or development of secondary rupture at the site of a hematoma in the bladder wall. Since CT may be a primary diagnostic study performed following abdominal trauma, the radiologist should be aware of CT findings suggesting bladder rupture and of the possibility of delayed presentation of this injury.

Cerebral arterial pulsatile flow changes and the effect of partial plasma exchange transfusion on these pulsatile flow patterns were studied in neonatal polycythemia/hyperviscosity syndrome by transcutaneous Doppler technique. Twenty-two infants with cord blood hematocrit greater than 58% (greater than 2 SD above the mean) were studied from a total of 2,400 infants who were screened for cord hematocrit over a 6-month period. Each of 22 infants had the following initial studies: radial artery hematocrit, viscosity, intracranial pressure measurement, and anterior cerebral arterial Doppler study to determine pulsatility index, mean systolic, mean end diastolic, and mean flow velocities, and area underneath the curve of the velocity tracings/min. Twelve of 22 infants had radial artery hematocrit less than 63%, were normoviscous (less than 13.5 cps, 11.25 sec-1) and were designated as control infants. Ten (study infants) were polycythemic (hematocrit greater than or equal to 63%) and hyperviscous (greater than or equal to 13.5 cps, 11.25 sec-1). All study patients were treated by partial plasma exchange transfusion. Initial studies were repeated after exchange transfusion. Control infants were not treated. Prior to exchange procedure, the polycythemic hyperviscous infants had significantly higher hematocrit, viscosity, and pulsatility index; the other Doppler measurements and heart rate were lower than those of control babies. The exchange procedure resulted in significantly decreased hematocrit, viscosity, and pulsatility index and increase in the other Doppler measurements, heart rate, and intracranial pressure. All postexchange measurements of study infants were not statistically different from the control infants. These data suggest that neonatal polycythemia/hyperviscosity syndrome may be associated with abnormal cerebral hemodynamics that could improve with partial plasma exchange transfusion.

A multicenter clinical study was conducted using iohexol, a second-generation nonionic contrast medium, for excretory urography performed in 130 children. Doses of iohexol (300 mg iodine/ml) ranged between 150 and 660 mgI/kg (0.5 and 2.2 ml/kg). Iohexol was tolerated well, and no significant adverse reactions occurred. Sixty-five iohexol urograms were evaluated to determine the minimum dose for adequate visualization of the kidneys and collecting systems. A dose greater than 300 mgI/kg (1.0 ml/kg) always resulted in a urogram of diagnostic quality, while visualization was insufficient for diagnosis in 10% of studies done with doses of 150-300 mgI/kg (0.5-1.0 ml/kg). Another 65 iohexol urograms were compared in a blinded manner with a similar number of studies performed using iothalamate meglumine at comparable iodine concentration and dose. Visualization of calyces and pelvoinfundibular structures achieved with iohexol was rated better with statistical significance, but there was no difference in visualization of the renal parenchyma or ureters. Use of iohexol in excretory urography may be advantageous in children who are at greatest risk for an adverse reaction to contrast media or in those most likely to benefit from use of a low osmolality contrast agent.

Intraperitoneal contrast material with CT scanning was used to evaluate three children with multiple recurrences of peritonitis and no obvious source of infection while they were undergoing continuous-cycling peritoneal dialysis. In one child a loculus of uno-pacified dialysate was readily identified, confirming sonographic findings that suggested an inflammatory pseudocyst. In the other two children, contrast material dispersed throughout the peritoneal dialysate, suggesting that recurrent peritonitis occurred from extraperitoneal contamination. CT peritoneography is easily performed with contrast material instilled through the peritoneal dialysis catheter. Combining anatomic imaging with intraperitoneal-fluid dynamics, this technique should provide more complete evaluation of the peritoneal cavity than other imaging methods. While additional evaluation is necessary, our initial experience suggests the usefulness of CT peritoneography in excluding an intraperitoneal source of infection during long-term peritoneal dialysis.

The 4p- syndrome results from a structural deficiency in chromosome 4. The clinical and radiologic findings in three patients with the 4p- syndrome are presented. Clinical, genetic, and radiologic findings in other reported cases are summarized. A widened interpubic distance with underdevelopment of the bony pelvis and deficiencies in ossification of the cervical spine are prominent radiologic features in our cases. Taken separately, these findings have limited differential diagnostic possibilities which are briefly discussed. The combination of these findings with characteristic clinical abnormalities is very suggestive of the 4p- syndrome and should prompt karyotyping for confirmation.

Fourteen children who experienced acute, profound central nervous system hypoxia secondary to near drowning, aspiration, or respiratory arrest underwent CT examination. During the first week after the episode, the most frequent finding was a loss of gray-white matter differentiation. Other findings included effacement of sulci and cisterns, focal areas of edema in the cerebral cortex or basal ganglia, and hemorrhagic infarctions of the basal ganglia. Subsequent CT scans obtained from two weeks to five months after the hypoxic episode showed progression of cerebral loss from cortical infarction with gyral hemorrhage and enhancement to global parenchymal atrophy. The prognosis is poor in these patients: seven children experienced severe neurologic deficits and seven died.

Good demonstration of retroperitoneal structures in the neonate can be obtained with real-time coronal ultrasonography. Advantages of coronal scanning include limited manipulation of the infant, less hindrance from monitoring devices or tubes when positioning the scanning probe, and improved visualization of retroperitoneal structures due to less interference by bowel gas. Retroperitoneal structures are displayed in conventional frontal anatomic relationships, which may facilitate recognition of renal ectopia and evaluation of abdominal masses. The authors' experience in evaluation of the neonatal retroperitoneum with coronal ultrasonography is presented.