Toddler with a central venous catheter that is difficult to infuse through and difficult to draw back from

Central catheter injection of thrombus at the tip of a central venous catheter — Scout image from a fluoro exam (left) shows the catheter is radiographically intact with its tip in the brachiocephalic vein. Images obtained during contrast injection (center and right) show contrast filling and outlining an irregularly shaped object at the tip of the catheter.

The diagnosis was central venous catheter malfunction due to a large thrombus at the tip of the catheter.

Newborn with an abdominal mass

CT of retroperitoneal teratoma — Axial (above), coronal (below left), and sagittal (below right) CT with contrast of the abdomen shows a large left-sided abdominal mass which arises from the retroperitoneum and crosses the midline and which displaces the left kidney inferiorly and posteriorly. The mass is heterogenous in nature and contains fat, is predominantly solid but has some cystic components, and it enhances minimally.

The diagnosis was retroperitoneal teratoma.

Teenager with lightheadedness and dizziness when their head is turned to the right or the left

MRA of otational vertebral artery occlusion syndrome of the right vertebral artery — Coronal 3D MRA without contrast of the neck with the head turned to the left (above left) and right (below left) shows focal narrowing of the right vertebral artery V3 segment in both positions. Coronal 3D MRA with contrast with the neck in a neutral position (right) shows a normal appearance to the vertebral arteries.

The diagnosis was rotational vertebral artery occlusion syndrome of the right vertebral artery.

Newborn with a brain cyst on prenatal ultrasound

MRI of intraventricular simple cyst — Axial (above left) and coronal (above right) T2 MRI and sagittal T1 MRI without contrast (below) of the brain show a thin walled round structure without septations in the posterior horn of the right lateral ventricle that follows cerebrospinal fluid signal characteristics on all MRI sequences.

The diagnosis was intraventricular simple cyst.

Teenager seen to ingest three non-food objects

AXR of battery and lead pencil in the stomach — AXR AP shows two radiopaque cylindrical objects in the abdomen. There is a faintly radiopaque thin straight object coursing from the T12-L1 intervertebral disk space to the left and ending just above the superior most cylindrical object.

The diagnosis was gastrointestinal foreign body in the form of two AA batteries and a lead pencil.

Newborn who has been abused

Radiograph and CT of Hangman cervical spine fracture — Lateral radiograph of the cervical spine (left) shows a large amount of prevertebral soft tissue swelling. There are fractures through the bilateral pedicles of the C2 vertebral body resulting in anterior translation of the C2 vertebral body on the C3 vertebral body. Sagittal CT without contrast of the cervical spine through the left (above center) and right (above right) pedicles better demonstrates the fractures through them as does the axial CT through the C2 vertebral body (below right).

The diagnosis was Hangman cervical spine fracture due to child abuse.

Infant on venous-venous extracorporeal membrane oxygenation after cardiac surgery with new bilateral pleural effusions

US of hemothorax as a complication of extracorporeal membrane oxygenation — CXR AP (above) shows correct position of the ECMO venous-venous catheter tip near the junction of the right atrium and the inferior vena cava. There are bilateral pleural effusions most prominently seen in the apex of the lungs. Transverse US of the right hemithorax (below left) shows echogenic pleural fluid lateral to the atelectatic right lower lobe. Sagittal US of the left hemithorax (below right) shows echogenic pleural fluid inferior to the atelectatic left lower lobe and superior to the spleen.

The diagnosis was correct position of the venous-venous ECMO catheter and bilateral hemothorax as a complication of extracorporeal membrane oxygenation.

Toddler with a newly placed central venous catheter that can be infused through but cannot be drawn back from

Radiograph of central venous cathetertip flush against the wall of the superior vena cava — CXR AP (above) shows the tip of the central venous catheter to be flush against the wall of the superior vena cava. Image taken during contrast injection of the central venous catheter (below) show the tip of the catheter has moved away from the wall of the superior vena cava during injection.

The diagnosis was pediatric central venous catheter malfunction because the tip of the catheter is flush against the wall of the superior vena cava.

Newborn with prenatal hydronephrosis

US of Tamm Horsfall proteins — Sagittal US of the kidneys shows multiple round echogenic foci in the renal pyramids bilaterally.

The diagnosis was Tamm Horsfall proteins.

Teenager with foot pain

Foot radiograph of psoriatic arthritis — AP radiographs of the feet show interphalangeal ankylosis and joint subluxation at the middle and distal interphalangeal joints in multiple phalanges bilaterally.

The diagnosis was psoriatic arthritis.

School ager with acute back pain and gait instability

MRI of myxopapillary ependymoma of the spinal cord — Sagittal T1 MRI without contrast (left), T2 MRI (center), and T1 MRI with contrast (right) of the lumbar spine shows an intradural extramedullary cylindrical solid mass that is arising from the filum terminale and which shows minimal enhancement. On T2 MRI (center) the mass has a triangular area of low signal intensity along its superior border (cap sign).

The diagnosis was a myxopapillary ependymoma of the spinal cord.

Teenager who has eaten something they should not have eaten

AXR of ingested AA batteries in the stomach — AXR AP shows two radiopaque cylindrical objects in the abdomen in the region of the stomach.

The diagnosis was a gastrointestinal foreign body in the form of two AA batteries.

Teenager hit by a car while riding their bike

Radiograph and CT of secondary accessory ossification center of vertebral body mimicking cervical spine fracture — Lateral radiograph of the cervical spine (left) shows a small ossific fragment anterior and superior to the C6 vertebral body. There is no prevertebral swelling and the alignment of the cervical spine is normal. Sagittal CT without contrast of the cervical spine (right) shows that the ossific fragment is well corticated.

The diagnosis was a secondary ossification center of the cervical spine mimicking a cervical spine fracture.

Newborn post intubation

CXR of left mainstem bronchus intubation — CXR AP shows the tip of the endotracheal tube is in the left mainstem bronchus. There is complete opacification of the right hemithorax.

The diagnosis was endotracheal tube malfunction with the tip of the endotracheal tube in the left mainstem bronchus resulting in complete atelectasis of the right lung.

School ager with ventriculoperitoneal shunt in clinic for routine followup

AXR of VP shunt migration from abdomen to chest — AXR taken 1 year ago (left) shows the VP shunt to be radiographically intact and its tip is coiled in the pelvis. AXR taken today (right) shows the VP shunt migrated out of the abdomen into the left chest and its tip is in the left costrophrenic angle.

The diagnosis was ventriculoperitoneal shunt malfunction due to shunt tip migration into the chest.

Teenager with abdominal pain and hematuria

CT of nutcracker syndrome — Axial CT with contrast of the abdomen shows stenosis of the proximal left renal vein with associated dilation of the distal left renal vein due to compression of the left renal vein between the superior mesenteric artery and aorta. There were no gonadal collaterals

The diagnosis was nutcracker syndrome.

School ager with a crooked stance

Radiograph of hemihypertrophy due to Parkes Weber syndrome — AP radiograph of the lower extremity shows a valgus deformity of the lower extremities. In addition, the soft tissues of the right thigh and calf are twice as thick as the soft tissues of the left thigh and calf.

The diagnosis was hemihypertrophy of the right lower extremity due to Parkes Weber syndrome.

Teenager with a C5-C6 fracture dislocation after a motor vehicle accident

MRA of vertebral artery dissection after trauma — MRA with contrast of the neck in AP (left) and left oblique (middle) and right oblique (right) projections shows the right vertebral artery arises from the right subclavian artery and courses normally to where it enters the basilar artery. The left vertebral artery arises from the left subclavian artery but then is only faintly visualized along its course until it reconstitutes where it enters the basilar artery.

The diagnosis was occlusion of the left vertebral artery from C2 to C7 due to dissection of the left vertebral artery.

Preschooler who has eaten something they should not have eaten

AXR of rare earth construction magnets in the stomach — AXR AP (left) and AXR lateral (right) show 4 radiopaque linear objects that are joined together in the mid abdomen.

The diagnosis was gastrointestinal foreign body in the form of 4 rare earth construction set magnets that are joined together.

School ager who fell from a horse and has pain in the middle of the right arm

Radiograph of bowing fracture of radius — AP (above) and lateral (below) radiographs of the right forearm show the radius is bowed in appearance when compared to the straightness of the ulna. No obvious fracture is seen.

The diagnosis was bowing fracture of the radius.

School ager post intubation

CXR of endotracheal tube in left mainstem bronchus — CXR AP (left) shows the tip of the endotracheal tube projecting over the left mainstem bronchus. CXR AP (middle) shows the tip of the endotracheal tube projecting over the right mainstem bronchus. CXR AP (right) shows the tip of the endotracheal tube projecting above the carina.

The diagnosis was endotracheal tube malfunction with the endotracheal tube placed initially in the left mainstem bronchus, then in the right mainstem bronchus and finally in the trachea above the carina.

School ager with a ventriculoperitoneal shunt and new neck pain

Radiograph of breakage of VP shunt tubing in the neck — Lateral radiograph of the skull taken 7 years ago (above) shows the VP shunt to be intact inferior to the lucent shunt reservoir. Current lateral radiograph of the skull (below) shows a discontinuity in the ventriculoperitoneal shunt inferior to the lucent shunt reservoir due to a breakage of the shunt tubing.

The diagnosis was ventriculoperitoneal shunt malfunction in the form of a breakage of the tubing in the neck.

Infant with a renal mass on prenatal ultrasound

CT of mesoblastic nephroma, cellular subtype — Coronal CT with contrast of the abdomen (below) shows a solid mass with variable enhancement with cystic components within the right kidney. Axial CT (above) shows the cystic component of the mass extends to the midline. No claw sign is present. The left kidney is normal.

The diagnosis was mesoblastic nephroma, cellular type.

School ager with a myelomeningocele who is insensate in the lower extremities who had left varus derotation osteotomy surgery 2 months ago and now has new left thigh swelling

Radiograph of congenital insensitivity to pain resulting in exuberant periosteal reaction — AP (left) and lateral (right) radiographs of the left femur show a normal post operative appearance to the left hip plate and screws. There is exuberant periosteal reaction present along the femur. There is an irregular lucency in the distal femoral metaphysis.

The diagnosis was congenital insensitivity to pain resulting in exuberant periosteal reaction from an undiagnosed nondisplaced distal femur fracture.

Teenager whose ventriculoperitoneal shunt was revised 1 month ago who now has a new headache and redness along the anterior abdominal wall.

CT of a CSFoma / cerebrospinal fluid pseudocyst in the anterior abdominal wall — Axial (above) and coronal (below) CT with contrast of the abdomen shows a round low density fluid collection in the subcutaneous tissues of the right anterior abdominal wall with inflammatory changes noted around the fluid collection. In the center of the fluid collection is a coiled ventriculoperitoneal shunt.

The diagnosis was ventriculoperitoneal shunt malfunction in the form of a CSFoma in the anterior abdominal wall due to VP shunt tip migration out of the abdomen.