School ager with long standing headaches who just had a VP shunt placed

Radiograph and CT of copper beaten skull — AP and lateral radiographs of the skull (above) show throughout skull vault prominence of convolutional markings from gyral impressions on the inner table of the skull, which is also well demonstrated on the axial CT without contrast of the brain (below).

The diagnosis was copper beaten skull caused by long-standing hydrocephalus in a patient with aqueductal stenosis.

Toddler with a big head

MRI of benign enlargement of the subarachnoid space — Axial T2 MRI without contrast of the brain shows a diffusely enlarged subarachnoid space being crossed by subarachnoid vessels. The ventricular system is normal in size.

The diagnosis was benign enlargement of the subarachnoid space.

Newborn with ventriculomegaly on prenatal ultrasound

US of aqueductal stenosis — Coronal (above) and sagittal (below) US of the brain show dilation of the lateral and third ventricles. The fourth ventricle is normal in size.

The diagnosis was aqueductal stenosis.

A patriotic toddler with increasing stridor over time

Pathological image of an esophageal foreign body — Lateral radiograph of the airway (left) shows a radiopaque foreign body in the cervical esophagus which is associated with a large amount of retropharyngeal soft tissue swelling. Gross pathological image (right) shows a metal flag-shaped pin that was endoscopically retrieved from the patient’s esophagus.

The diagnosis was gastrointestinal foreign body which had been present for a long period of time.

Newborn with prenatal US showing polyhydramnios and a double bubble sign

Clinical image of duodenal atesia — Clinical image shows a massively distended abdomen.

The diagnosis was duodenal atresia.

Newborn with vomiting

Surgical image of duodenal stenosis — Surgical image shows a massively dilated second part of the duodenum in the center of the image. The decompressed proximal jejunum, being pinched between the thumb and forefinger, is seen to the left and inferior to the dilated duodenum.

The diagnosis was duodenal stenosis.

Preschooler with epigastric discomfort, especially when laying down to go to bed at night, who had a loop of bowel behind the sternum incidentally noted on a CXR

Surgical image of Morgagni hernia — Surgical image shows an anterior midline defect in the diaphragm, measuring 7 cm in width by 3 cm in depth. The transverse colon was herniated through this defect into the retrosternal space and had been reduced before this image was obtained.

The diagnosis was Morgagni hernia.

Newborn with respiratory distress

Gross pathological image of congenital diaphragmatic hernia — Gross pathological image shows portions of the intestine and spleen in the left hemithorax causing the heart to be displaced into the right hemithorax.

The diagnosis was left-sided congenital diaphragmatic hernia.

Preschooler who stools out of her vagina and rectum and is known to have a duplicated colon

Surgical image of colonic duplication — Surgical image shows the duplicated colon at the level of the sigmoid colon with the two colonic lumens running side by side. The mucosa was removed from the duplicated colon from the level of its sigmoid colon to the vaginal orifice. The duplicated colon was then anastomosed to the normal colon at the level of the normal colon’s sigmoid colon.

The diagnosis was colonic duplication.

Preschooler who stools out of her vagina and rectum and is known to have a duplicated colon

Clinical image of colonic duplication — Clinical image shows a normal anus and a probe in an extra orifice in the posterior vaginal wall which communicates with the second colonic lumen.

The diagnosis was colonic duplication.

Teenager with abdominal pain

Surgical image of acute appendicitis — Surgical image shows the appendix to be grossly inflamed with exudate, but not to be perforated.

The diagnosis was acute appendicitis.

Newborn female with an absent anus who stools out of her vagina

Clinical image of anorectal malformation — Clinical image shows normal appearing external genitalia, but no anus. Examination of the vaginal introitus reveals a rectal fistula to the posterior vaginal fourchette in the midline, located just inferior to the vagina.

The diagnosis was anorectal malformation with rectovaginal fistula to the vaginal fourchette.

Newborn with an absent anus

Clinical image of anorectal malformation — Clinical image shows meconium exiting the urethral meatus.

The diagnosis was anorectal malformation.

Newborn with ventriculomegaly on prenatal ultrasound

MRI of aqueductal stenosis — Axial (above left) and coronal (above right) T1 MRI without contrast of the brain show dilation of the lateral and third ventricles. Sagittal T2 MRI without contrast of the brain (below) shows narrowing at the aqueduct of Silvius with a decreased amount of CSF within it. The fourth ventricle is normal in size.

The diagnosis was aqueductal stenosis.

Newborn with a large head

US of aqueductal stenosis — Coronal (left) and sagittal (right) US of the brain show dilation of the lateral and third ventricles. The fourth ventricle is normal in size.

The diagnosis was aqueductal stenosis.

Our DDX For This Week Is

View the illustrated DDX of hydrocephalus

Newborn with bilious vomiting and a double bubble sign on AXR

Surgical image of duodenal atresia — In the operating room the duodenum was seen to taper between its second and third portions. A nasogastric tube could not be advanced past this area of tapering. There appeared to be a membrane obstructing the duodenum at this point. A duodenotomy was performed which confirmed the presence of a thick membrane completely obstructing the duodenum. Bile was seen above and below this membrane. The bile was coming from one papilla above the membrane and one papilla below it. Surgical image shows the superior retractor distracting the proximal duodenum and the inferior retractor distracting the distal duodenum. The obstructing membrane is seen between the retractors. The obstructing membrane was then incised.

The diagnosis was duodenal atresia.

Pediatric Imaging Pearl of the Week

View the illustrated DDX of complications of mastoiditis

Preschooler with fever and right facial tenderness

CT of mastoiditis with dural venous sinus thrombosis — Axial CT with contrast of the brain with bone windows (left) shows complete opacification of the mastoid air cells bilaterally. MRV with contrast of the brain (right) shows a lack of venous flow in the right sigmoid sinus.

The diagnosis was acute mastoiditis with thrombosis of the right sigmoid sinus.

Preschooler with chickenpox and a left earache

CT of acute mastoiditis — Axial CT with contrast of the brain with bone windows (left) shows partial opacification of the left mastoid air cells and a lower image with soft tissue windows (right) shows inflammation in the left neck soft tissues at the level of the left mastoid air cells.

The diagnosis was acute mastoiditis.

Toddler with left earache

CT of mastoiditis with Bezold abscess — Axial CT with contrast of the brain with bone windows (left) shows opacification of the left mastoid air cells and the same image with soft tissue windows (right) shows a low density rim enhancing fluid collection at the level of the left mastoid air cells deep to the sternocleidomastoid and trapezius muscles.

The diagnosis was acute mastoiditis with a Bezold abscess.

Infant with left otitis media and left neck swelling

CT of coalescent mastoiditis — Axial and coronal CT with contrast of the neck with soft tissue windows (above) show extensive left cervical adenopathy and inflammation. Axial CT with contrast of the neck with bone windows (below) show bilateral complete opacification of the mastoid air cells and subtle erosive changes in the anterior aspect of the left temporal bone. There were no intracranial findings.

The diagnosis was left coalescent mastoiditis.

School ager with pus draining from the right ear

CT of coalescent mastoiditis with intracranial abscess — Axial CT with contrast of the brain with bone windows (left) shows opacification and destruction of the right mastoid air cells while axial CT with contrast of the brain with soft tissue windows (right) shows a large low density ring enhancing lesion in the right cerebral hemisphere that is causing midline shift to the left.

The diagnosis was right coalescent mastoiditis with an intracranial abscess.

Our DDX For This Week Is

View the illustrated DDX of complications of mastoiditis

Teenager with crampy abdominal pain and vomiting

Gross pathological image of Chron disease — Gross pathological image shows a normal cecum and appendix (right of image) and a stricture at the terminal ileum (middle of image), which is thickened. The terminal ileum is ulcerated with pseudopolyp formation at the stricture. Histopathology showed transmural inflammation of the terminal ileum with granuloma formation and ulceration.

The diagnosis was Crohn Disease.