Teenager with growth hormone deficiency

MRI of Rathke cleft cyst — Sagittal T1 MRI with contrast of the sella shows an oval non-enhancing lesion located between the anterior and posterior aspects of the pituitary gland.

The diagnosis was Rathke cleft cyst.

Teenager with hyperprolactinemia

MRI of pituitary microadenoma — Sagittal (above) and coronal (below) T1 MRI with contrast of the sella shows a small mass in the midline of the sella that enhances less than the surrounding pituitary gland.

The diagnosis was pituitary microadenoma.

Teenager with short stature

MRI of pituitary macroadenoma — Sagittal (above) and coronal (below) T1 MRI with contrast of the sella shows a large homogenous solid mass arising in the sella and extending superiorly into the suprasellar region that shows homogenous enhancement with contrast.

The diagnosis was pituitary macroadenoma.

School ager with growth hormone deficiency

MRI of pituitary interrupted stalk syndrome — Sagittal (above) and coronal (below) T1 MRI without contrast of the sella shows absence of the pituitary stalk between the sella and the hypothlamus. In addition, the high signal intensity posterior pituitary bright spot, which should be located posteriorly in the sella turcica, is instead located in the inferior aspect of the hypothalamus.

The diagnosis was pituitary interrupted stalk syndrome and ectopic posterior pituitary.

Preschooler with growth hormone deficiency

MRI of ectopic posterior pituitary gland — Sagittal T1 MRI without (above) and with contrast (below) of the sella shows the high signal intensity posterior pituitary bright spot, which should be located posteriorly in the sella turcica, is instead located in the superior aspect of the pituitary stalk / inferior aspect of the hypothalamus. The pituitary gland is otherwise unremarkable.

The diagnosis was ectopic posterior pituitary.

School ager with hypopituitarism

MRI of craniopharyngioma — Lateral radiograph of the skull (top image) shows an enlarged sella turcica. Sagittal TI MRI without and with contrast of the sella (middle two images) shows a large heterogenous mass arising in the sella and extending superiorly into the suprasellar region that shows primarily rim enhancement with contrast. Coronal T2 MRI of the sella (bottom image) shows the sellar and suprasellar mass to have a high signal intensity implying it has cystic and or proteinaceous components.

The diagnosis was craniopharyngioma.

Our DDX For This Week Is

View the illustrated DDX of pituitary gland lesions.

Teenager with crampy abdominal pain and vomiting

Surgical image of Crohn disease — Surgical image shows the terminal ileum, which is between the two forceps, to be thickened in nature, firm to palpation and to have mesenteric fat wrapped around it. The appendix is normal in appearance.

The diagnosis was Crohn disease.

Pediatric Imaging Pearl of the Week

View the illustrated DDX of hydrocephalus

Newborn with hydrocephalus on prenatal ultrasound

US of hydranencephaly — Coronal US of the brain (above) shows only the thalamus in the midline surrounded by fluid in the supratentorial region of the brain. No discernable lateral and third ventricles are seen and no rim of cortical parenchyma could be appreciated. Sagittal US of the brain (below) shows the cerebellum to be normal in appearance.

The diagnosis was hydranencephaly.

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.