Teenager with left orbital and forehead swelling

CT of Pott puffy tumor and subdural empyema — Sagittal CT with contrast of the brain shows frontal and left maxillary sinusitis and extensive soft tissue swelling anterior to the forehead (upper left) and destruction of the anterior left frontal bone in the frontal sinus and extensive soft tissue swelling anterior to the left orbit (upper right). Coronal (lower left) and sagittal (lower right) T1 MRI with contrast of the brain shows diffuse meningeal enhancement, subdural empyemas along the falx and both cerebral convexities, and multiple large non-enhancing subgaleal fluid collections in the left scalp.

The diagnosis was meningitis, subdural empyema, and Pott puffy tumor as complications of sinusitis.

School ager with left eye swelling

CT of subperiosteal abscess — Axial CT with contrast of the orbits shows opacification of the left ethmoid sinus and bilateral sphenoid sinuses along with pre and post-septal inflammation of the left orbit. A lenticular fluid collection with rim enhancement is present along the medial wall of the left orbit.

The diagnosis was orbital cellulitis with a subperiosteal abscess.

Preschooler with right eye swelling

CT of orbital cellulitis — Axial CT with contrast of the orbits shows opacification of the bilateral ethmoid and maxillary sinuses along with pre and post-septal inflammation of the right orbit. No subperiosteal abscess was seen.

The diagnosis was orbital cellulitis.

School ager who does not take care of their teeth and had a seizure

MRI of intracranial abscess due to sinusitis — Axial T2 MRI of the brain (above left) shows a mass in the right front lobe with surrounding vasogenic edema. Axial (above right) and coronal (below right) T1 MRI with contrast shows the mass to have thin rim enhancement and the coronal image also shows left maxillary sinusitis. The mass is shown to demonstrate diffusion restriction on diffusion-weighted imaging (below left).

The diagnosis was intracranial abscess as a complication of sinusitis.

Our DDX For This Week Is

View the illustrated DDX of complications of sinusitis.

Teenager with bilateral knee swelling who has untreated Lyme disease

Radiograph of lyme arthritis of the knees — AP and lateral radiographs of the right knee (above) and left knee (below) shows large bilateral suprapatellar joint effusions, right greater than left.

The diagnosis was Lyme disease in the form of Lyme arthritis.

Teenager with right flank pain

Ultrasound of dromedary hump — US of the left kidney (below) shows a prominent focal bulge on its lateral border that is not present on the lateral border of the right kidney (above).

The diagnosis was dromedary hump of the left kidney.

Toddler with stridor since birth

Surgical image of right aortic arch with aberrant left subclavian artery — Surgical image taken through a left thoracotomy shows a blue vessel loop around the ligamentum arteriosum which was compressing the esophagus posterior to it. The red vessel loops are around the right aortic arch (on the right) and the left subclavian artery (on the left). The vascular ring was subsequently divided by division of the ligamentum arteriosum. The vascular ring then sprang open dramatically, relieving its compression upon the esophagus.

The diagnosis was right aortic arch with aberrant left subclavian artery and ligamentum arteriosum forming an incomplete vascular ring.

Pediatric Imaging Pearl of the Week

View the illustrated DDX of malformations of cortical migration

Infant with hydrocephalus on prenatal ultrasound

CT of right open lip schizencephaly — Axial CT without contrast of the brain shows a cerebrospinal fluid tract communicating between the right occipital cortex and the posterior horn of the right lateral ventricle that was felt to be lined by gray matter on both sides.

The diagnosis was right open lip schizencephaly.

School ager with seizures

MRI of perisylvian polymicrogyria and open lip schizencephaly — Coronal and axial T1 (above) and axial T2 (below) MRI without contrast of the brain shows small haphazard appearing gyri and too few sulci present bilaterally, left greater than right, primarily in the sylvian fissures. There is also a cleft of gray matter with cerebrospinal fluid within extending from the cortex to the posterior aspect of the left lateral ventricle.

The diagnosis was polymicrogyria in a patient with left open lip schizencephaly.

Newborn with macrocephaly

MRI of perisylvian polymicrogyria — Axial T2 (above) and coronal T1 (below) MRI without contrast of the brain shows small haphazard appearing gyri and too few sulci present bilaterally, primarily in the sylvian fissures.

The diagnosis was polymicrogyria.

Newborn with abdominal distension after placement of a nasogastric tube

Surgical image of gastric perforation — Surgical image shows the surgical forceps in the center of the image delineating the size of the hole in the antrum of the stomach.

The diagnosis was gastric perforation.

Newborn with respiratory distress

Gross pathological image of asphyxiating thoracic dystrophy — Post-mortem gross pathological image shows an extremely small thorax due to shortened ribs, particularly when compared to the size of the abdomen.

The diagnosis was asphyxiating thoracic dystrophy.

Newborn who is lacking a cranial vault on physical exam

Pathological image of anencephaly — Post-mortem gross pathological image shows flattening of the top of the skull due to the absence of a cranial vault.

The diagnosis was anencephaly.

Newborn with hydrocephalus on prenatal ultrasound

MRI of lissencephaly type I classic — Axial T1 (left) and axial T2 (right) MRI without contrast of the brain shows a decreased number of gyri and sulci resulting in a nearly smooth brain. There is ventriculomegaly. Overall the brain has an hourglass or figure of 8 appearance.

The diagnosis was lissencephaly type I classic.

Infant with meningomyelocele who has had a VP shunt placed

MRI of heterotopia — Axial (left) and coronal (right) T2 MRI without contrast of the brain shows multiple subependymal nodules along the lateral wall of the left lateral ventricle that have signal characteristics similar to those of gray matter. Similar lesions were found in the right lateral ventricle on images that did not contain artifact from the right parietal VP shunt.

The diagnosis was heterotopia.

Our DDX For This Week Is

View the illustrated DDX of malformations of cortical migration

Infant with choking with feeding

Surgical image through a thoracotomy incision (left) shows blue vessel loop around an aberrant left subclavian artery arising from a Kommerell diverticulum. Black suture loop is around a patent ductus arteriosus that was noted to extend from the Kommerell diverticulum and completed a vascular ring which was compressing the esophagus posterior to it. Surgical image (right) with the patent ductus arteriosus mobilized off the esophagus which is between the tips of the hemostat show the esophagus now resorting to its normal caliber.

The diagnosis was right aortic arch with aberrant left subclavian artery and patent ductus arteriosus forming a complete vascular ring.

Pediatric Imaging Pearl of the Week

View the illustrated DDX of phakomatoses

Toddler with seizures

MRI of tuberous sclerosis — Axial T2 MRI without contrast of the brain (left) shows three rounded low intensity subependymal lesions along the lateral aspect of the left lateral ventricle. Axial FLAIR MRI image without contrast of the brain (right) shows multiple bilateral poorly defined hyperintense areas located just beneath the cortex of the brain.

The diagnosis was multiple subependymal nodules and subcortical tubers in tuberous sclerosis.

School ager with seizures

MRI of tuberous sclerosis — Coronal FLAIR MRI images without contrast of the frontal (above left), middle (above right) and posterior (below) aspects of the brain shows multiple bilateral poorly defined hyperintense areas located just beneath the cortex of the brain.

The diagnosis was multiple subcortical tubers in tuberous sclerosis.

School ager with seizures

CT of Sturge-Weber syndrome — Axial CT with contrast of the brain shows diffuse leptomeningeal enhancement involving the right temporal and parietal and occipital lobes, an enlarged enhancing right choroid plexus, an enlarged medullary vein draining into the deep venous system, and some mild atrophy of the right cerebral hemisphere.

The diagnosis was Sturge-Weber syndrome.

Preschooler with seizures

MRI of optic pathway gliomas in neurofibromatosis type I — Axial (left) and coronal T1 MRI with contrast of the orbits shows marked thickening of the optic nerves bilaterally.

The diagnosis was bilateral optic pathway gliomas in a patient with neurofibromatosis type I.

Preschooler with cafe au lait spots

MRA of Moya Moya syndrome in neurofibromatosis type I — AP view of a 3D maximum intensity projection of an MRA of the neck with contrast (above) and AP (below left) and inferior (below right) views of a 3D maximum intensity projection of an MRA of the brain without contrast shows diffuse hypoplasia of the left internal carotid artery. There is stenosis and occlusion of the cavernous and supraclinoid segments of the left internal carotid artery and then there is a thin left M1 segment without evidence of collaterals in the basal ganglia. Additionally, aneurysms are noted in the left A1 and A2 segments.

The diagnosis was Moya Moya syndrome in a patient with neurofibromatosis type I.