Pediatric Imaging Pearl of the Week

The illustrated DDX can be found here.

School ager with diminished femoral pulses

CXR of coarctation of aorta — CXR AP shows a 3 sign in the region of the aortic arch and bilateral rib notching.

The diagnosis was coarctation of the aorta.

School ager with dyspnea

CXR of pericardial effusion — CXR AP shows normal pulmonary vasculature and an enlarged water bottle-shaped heart.

The diagnosis was pericardial effusion. 375cc of chylous fluid were drained out of the pericardium.

Newborn with cyanosis

CXR of Ebstein anomaly — CXR AP shows decreased pulmonary vascularity and a huge box-shaped heart.

The diagnosis was Ebstein anomaly.

Preschooler with cyanosis

CXR of tetralogy of Fallot — CXR AP shows decreased pulmonary blood flow and an upturned cardiac apex resulting in a boot-shaped heart.

The diagnosis was tetralogy of Fallot.

School ager with dyspnea

CXR and angiogram of partial anomalous pulmonary venous return — CXR AP (above) shows a hypoplastic right lung, AP arterial (left) and venous (right) phases of a pulmonary artery angiogram show a right pulmonary (scimitar) vein draining into the inferior vena cava.

The diagnosis was partial anomalous pulmonary venous return.

Infant with cyanosis

CXR and angiogram of total anomalous pulmonary venous return — CXR AP (above) shows increased pulmonary blood flow and a snowman-shaped heart, AP angiogram venous phase (below) shows dilated superior vena cava on right and left vertical vein on left.

The diagnosis was total anomalous pulmonary venous return – supradiaphragmatic.

Infant with cyanosis

CXR of transposition of the great arteries — CXR AP shows increased pulmonary blood flow and an egg on a string-shaped heart.

The diagnosis was transposition of the great arteries.

Our DDX For This Week Is

Pediatric Imaging Pearl of the Week

The illustrated DDX can be found here.

Newborn with new abdominal distension with a patent ductus arteriosus who is receiving indomethacin to close it

AXR of pneumoperitoneum — Right lateral decubitus radiograph of the abdomen shows a large amount of free air within the abdomen.

The diagnosis was indomethacin-induced bowel perforation.

Infant with hypoplastic left heart syndrome on prostaglandin E to keep their ductus arteriosus patent who is continuously vomiting with feeds

UGI and US of prostaglandin E induced gastritis — Two lateral images from an upper GI (above) show persistent narrowing of the pylorus causing relative gastric outlet obstruction. Sagittal (left below) and transverse (right below) US of the pylorus shows the central echogenic gastric mucosa to be thickened and the pyloric muscle outside of it to be normal in diameter. The patient was also noted to be malrotated.

The diagnosis was prostaglandin E induced gastritis.

Infant with tracheomalacia and concern for vascular ring

CT of calcified ligamentum arteriosum — Axial CT with contrast of the chest shows a linear crescent-shaped calcification just to the left of the trachea which appears to join the main pulmonary artery to the descending aorta. An outside institution misinterpreted this calcification as a fish bone perforating out of the esophagus and transferred the patient emergently to our institution.

Infant with a murmur

CXR of patent ductus arteriosus ductus diverticulum — CXR AP shows mild cardiomegaly and pulmonary vascular congestion along with an extra soft tissue mass just to the left of the spine near the presumed position of the ductus arteriosus.

The diagnosis was a ductus diverticulum in a patient with patent ductus arteriosus.

Infant with murmur

Angiogram of patent ductus arteriosus — AP angiogram while injecting the pulmonary artery shows simultaneous filling of the descending aorta.

The diagnosis was patent ductus arteriosus.

Newborn with a murmur

CXR AP at 1 day of life (above) and 1 year of life (below) shows interval development of cardiomegaly and pulmonary vascular congestion.

The diagnosis was patent ductus arteriosus.

Our DDX For This Week Is

Pediatric Imaging Pearl of the Week

Preschooler who was abused

Radiographs of a healing skull fracture — Lateral radiograph of the skull initially (left) showed bilateral linear parietal lucencies coursing across the skull which are no longer seen 4 months later (right).

The diagnosis was healing skull fractures.

Infant who fell 3 feet out of bed onto a wooden floor

CT of an (not) accessory skull suture — 3D reconstruction from CT without contrast of the brain (left) shows a linear straight lucency that connects to the left lambdoid suture. Coronal CT (right) shows the same linear lucency lying under a large subgaleal hematoma.

The diagnosis was a linear skull fracture and not an accessory suture of the skull based on the soft tissue swelling associated with the linear lucency.

Toddler in a motor vehicle accident 2 months ago who still has a soft spot on the skull in the region of the fracture

Radiography of a growing skull fracture (leptomeningeal cyst) — 3D CT reconstruction initially (left) showed a diastatic skull fracture which has increased in size on the lateral radiograph of the skull (right) taken 2 months later.

The diagnosis was a growing skull fracture / leptomeningeal cyst.

Preschooler hit in the head with a golf club

CT of a depressed skull fracture — Axial CT without contrast of the brain shows depression of the skull in the left temperoparietal region with an associated subgaleal hematoma containing subcutaneous air.

The diagnosis was a depressed skull fracture.

Toddler in a motor vehicle accident

CT of a diastatic skull fracture — 3D reconstruction from a CT without contrast of the brain shows a wide right parietal lucency between two separated fragments of bone.

The diagnosis was a diastatic skull fracture.

Preschooler who has been abused

Radiograph of a linear skull fracture — Lateral radiograph of the skull shows bilateral linear parietal lucencies coursing across the skull.

The diagnosis was bilateral linear skull fractures.

Our DDX For This Week Is