Our DDX For This Week Is

Teenager status post central catheter placement

CXR showing central venous catheter tip malpositioned in the right internal thoracic vein — CXR AP obtained immediately after catheter placement (above) shows the catheter tip malpositioned in the right internal thoracic vein. CXR AP obtained after repositioning (below) shows catheter tip appropriately positioned in the superior vena cava.

The diagnosis was malpositioned catheter tip after placement.

Preschooler with a dual port central catheter whose white port is not working well

Line study showing dual port central venous catheter — Image from a line study while injecting the white port of the catheter (left lower) shows the lumen of the white port is one-third the diameter seen while injecting the red port of the catheter (right lower). No fibrin sheath or clot was seen.

The diagnosis was a normal appearance of a dual port central catheter.

School ager who presents with back pain after having a central venous catheter replaced 5 months ago

CXR and CT of embolized central venous catheter fragment — CXR AP shows the tip of the new catheter to be in appropriate location in the superior vena cava. There is a catheter fragment in the right lower lobe along with a large right pleural effusion. Axial CT with contrast of the chest shows the embolized catheter fragment in the periphery of the right lower lobe and to have eroded into the right pleural space, with an associated pleural effusion and atelectasis.

The diagnosis was an embolized catheter fragment after catheter removal.

Newborn with a solid renal mass on prenatal ultrasound.

Surgical image of mesoblastic nephroma — Surgical image shows an extremely large right renal tumor displacing the cecum into the left lower quadrant.

The diagnosis was mesoblastic nephroma.

Pediatric Imaging Pearl of the Week

The illustrated DDX can be found here.

Infant with a new right scrotal bulge

AXR and US of ventriculoperitoneal shunt tip in the scrotum — AXR (above) shows the tip of the VP shunt has migrated into the right scrotum. Transverse US image (below) shows a moderate left hydrocele and the round VP shunt catheter in the medial aspect of the right scrotum.

The diagnosis was migration of the VP shunt catheter tip through the right inguinal canal into the right scrotum.

Newborn with a prenatal diagnosis of hydrocephalus, status post VP shunt placement

CT of over-shunting — Initial axial CT without contrast of the brain (above) showed marked dilation of the lateral, third and fourth ventricles. Axial CT without contrast of the brain 1 day after shunt placement (below) shows interval decompression of the ventricular system and interval development of large bilateral subdural hygromas.

The diagnosis was subdural hygroma development due to over-shunting.

Infant with increasing abdominal distension over 4 days

CT of CSFoma — Axial CT with intravenous and oral contrast of the abdomen shows an extremely large mass filling the abdomen with the tip of the VP shunt within it which is causing hydronephrosis and displacement of the bowel.

The diagnosis was VP shunt malfunction due to a CSFoma.

Preschooler status post VP shunt replacement 1 hour ago

CT of ventriculoperitoneal shunt malfunction — Axial CT without contrast of the brain obtained postoperatively shows a VP shunt catheter placed from a right parietal approach whose tip lies within the brain parenchyma.

The diagnosis was VP shunt malfunction due to malposition of the shunt tip within the brain parenchyma.

Preschooler with a new palpable prominence over the region of the VP shunt in the neck

Radiograph of ventriculoperitoneal shunt malfunction — AP and lateral radiographs of the skull and an AP radiograph of the abdomen shows a discontinuity between the reservoir of the VP shunt in the neck and the remainder of the VP shunt in the abdomen.

The diagnosis was VP shunt malfunction due to shunt discontinuity.

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.