Newborn with myelomeningocele with fever who is status post recent VP shunt placement and whose CSF is positive for infection

CT of ventriculitis — Axial CT with contrast of the brain shows subependymal enhancement throughout the ventricular system.

The diagnosis was an infected VP shunt with ventriculitis.

Infant with a low grade fever and redness and swelling around the VP shunt reservoir

CT of abscess around a ventriculoperitoneal shunt — Axial CT without contrast of the brain shows a low density fluid collection around the VP shunt reservoir between the skull and the scalp. In the operating room this fluid was found to be pus.

The diagnosis was an abscess around the VP shunt reservoir.

Toddler who is fussy and crying

CT of ventriculoperitoneal shunt malfunction — Axial T2 MRI without contrast of the brain (above) obtained 2 months ago shows normal ventricular size with a VP shunt in place. Axial CT without contrast of the brain (below) shows interval marked dilation of the lateral and third ventricles with transependymal flow of cerebrospinal fluid. The VP shunt series showed no radiographic abnormality of the VP shunt.

The diagnosis was VP shunt malfunction due to occlusion of the VP shunt.

School ager with headaches

Radiograph of ventriculoperitoneal shunt malfunction — AP and lateral radiographs of the skull show a kink in the VP shunt in the middle of the neck.

The diagnosis was VP shunt malfunction due to kinking of the shunt.

Preschooler with 2 weeks of abdominal distension

Radiograph and ultrasound of CSFoma — AP and lateral radiographs of the abdomen show the VP shunt to be coiled upon itself and there is a suggestion of a retrogastric mass on the lateral view. Transverse US of the left upper quadrant of the abdomen shows a large cystic structure with the VP shunt tip within it.

The diagnosis was VP shunt malfunction due to CSFoma.

School ager at yearly VP shunt checkup without any symptoms

Radiograph of ventriculoperitoneal shunt malfunction — AP and lateral radiographs of the abdomen shows the distal portion of the VP shunt to be broken into multiple fragments.

The diagnosis was VP shunt malfunction due to broken shunt.

Toddler with increased fussiness

Radiograph of ventriculoperitoneal shunt malfunction — AP and lateral radiographs of the skull shows migration of the VP shunt catheter tip out of its right-sided burr hole in the skull.

The diagnosis was VP shunt malfunction due to migration of the catheter tip out of the skull.

Toddler with increasing sommulence

Radiograph and CT of ventriculoperitoneal shunt malfunction — AP radiograph of the skull shows a discontinuity between the tip of the VP shunt and the rest of the VP shunt. Axial, coronal, and sagittal CT without contrast of the brain shows marked hydrocephalus with transependymal flow of cerebrospinal fluid.

The diagnosis was VP shunt malfunction due to shunt discontinuity.

Our DDX this week is

Newborn with several days of bilious vomiting

Surgical image — Surgical image shows the entire small bowel, from the jejunum to the terminal ileum, to be infarcted.

The diagnosis was malrotation with midgut volvulus.

Pediatric Imaging Pearl of the Week

The illustrated DDX can be found here.

Preschooler with a catheter that does not draw back

Line study of an occluded central venous catheter due to migration — CXR from 3 months before (above) shows the tip of the catheter in appropriate position in the superior vena cava. Scout image from the line study (below) shows interval migration of the tip of the catheter so that its tip now lies nearly flush against the lateral wall of the superior vena cava.

The diagnosis was occlusion of the catheter tip due to catheter migration.

School ager with a catheter that infuses but does not draw back

Line study of a thrombus on a central venous catheter — Scout image from a line study (above) shows migration of the tip of the catheter 90 degrees so that it now lies flush against the anterior wall of the superior vena cava. AP and lateral views from the line study after contrast injection shows staining of a long thin object resembling thrombus hanging off the tip of the catheter.

The diagnosis was thrombus of the catheter tip and occlusion of the catheter tip due to catheter migration.

Preschooler with a catheter that infuses but does not draw back

Line study of occluded central venous catheter due to migration — Scout image from a line study shows migration of the tip of the catheter so that it now lies flush against the lateral wall of the superior vena cava.

The diagnosis was occlusion of the catheter tip due to catheter migration.

Teenager with a catheter that infuses but does not draw back

Line study of a thrombus on a central venous catheter — Scout image from a line study (above) shows the tip of the catheter in the superior vena cava. Injection of contrast (below) shows staining of a large irregularly shaped object resembling thrombus at the tip of the catheter.

The diagnosis was thrombus of the catheter tip.

Teenager with a catheter that infuses but does not draw back

Line study of a fibrin sheath on a central venous catheter — Image from a line study (above) with the catheter filled with contrast shows a mild dilation in the diameter of the distal catheter, suggesting the contrast is inside a sheath encasing the distal catheter. When contrast is injected through the catheter (below), a sheath is seen to flip off the tip of the catheter to the left.

The diagnosis was fibrin sheath of the catheter tip.

School ager with a catheter that does not infuse and does not draw back

Line study of a central venous catheter port that was not correctly accessed — Image from a catheter injection (below) shows extravasation of contrast into the soft tissues of the chest wall adjacent to the tip of the needle. Closer review of the CXR scout (above) shows the tip of the needle being used to access the port is not within the port.

The diagnosis was the port was not correctly accessed.

Preschooler with a catheter that is difficult to infuse

Line study of a fibrin sheath on a central venous catheter — CXR obtained 6 months before (above left) compared to the scout image obtained before the line study (above right) shows the tip of the catheter has migrated proximally the height of one vertebral body between the two exams. Image from the line study (below) shows contrast outlining a sheath where the catheter tip used to be.

The diagnosis was fibrin sheath where the tip of the catheter was previously.

Preschooler who is immune suppressed with a fever who had their catheter replaced 9 months ago

CT of an embolized fibrin sheath from a central venous catheter — CXR shows no evidence of pneumonia, but suggests the presence of a tubular structure in the inferior aspect of the left hilum that was not present on a prior CXR obtained before the catheter was replaced. Coronal image from a CT with contrast of the chest better demonstrates the high density tubular structure.

The diagnosis was an embolized fibrin sheath from the prior catheter which was determined by an angiogram.

School ager with a catheter that does not infuse

Line study of a leaking central venous catheter port — AP and lateral views from a line study shows contrast leaking out of and all around the port into the subcutaneous tissues with no contrast entering the catheter.

The diagnosis was a leaking central venous catheter port.

Infant with catheter that infuses but does not draw back

Line study of central venous catheter with an occluded tip — CXR from 2 weeks earlier (above) shows the tip of the catheter in appropriate position at the junction of the superior vena cava and the right atrium. Scout image from a line study (below) shows the tip of the catheter has migrated backwards in the interval and its tip now rests against the wall of the superior vena cava.

The diagnosis was occlusion of the catheter tip due to catheter migration.

Preschooler with catheter that infuses but does not draw back

Line study of a fibrin sheath on a central venous catheter — Image from a line study (above) shows a subtle dilation in the diameter of the distal catheter, which is better seen on the magnified view (below), suggesting the contrast is inside a sheath encasing the distal catheter.

The diagnosis was fibrin sheath of the catheter tip.

Preschooler with catheter that has pain with infusion and that does not draw back

Line study of a leaking central venous catheter — Image from a line study while injecting contrast shows leakage of contrast out of the proximal portion of the catheter.

The diagnosis was leaking catheter.

Teenager with catheter that infuses but does not draw back

Line study of a fibrin sheath on a central venous catheter — Scout from a line study (above) shows the tip of the catheter to be abnormally positioned in the right subclavian vein rather than in the superior vena cava. Injection of the catheter (below) shows a dilation in the diameter of the distal catheter, suggesting the contrast is inside a sheath encasing the distal catheter.

The diagnosis was fibrin sheath of the catheter tip.

School ager with catheter that infuses but does not draw back

Line study of a central venous catheter tip that has migrated out of the vessel — CXR from 1 month before (above) shows the tip of the catheter in a left-sided superior vena cava. Scout image from a line study (below left) shows the tip of the catheter has apparently migrated out of the left-sided superior vena cava. Injection of the catheter (below right) shows contrast extravasating into the mediastinum.

The diagnosis was migration of the catheter tip out of the vessel into the mediastinum.