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.

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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.

Pediatric Imaging Pearl of the Week

View the illustrated DDX of complications of sinusitis.

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.

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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 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.

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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 bilateral perisylvian 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 bilateral perisylvian 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.