School ager with a catheter that does not infuse and does not draw back

Line study of a central venous catheter port that was not correctly accessed — Image from a catheter injection (below) shows extravasation of contrast into the soft tissues of the chest wall adjacent to the tip of the needle. Closer review of the CXR scout (above) shows the tip of the needle being used to access the port is not within the port.

The diagnosis was the port was not correctly accessed.

Preschooler with a catheter that is difficult to infuse

Line study of a fibrin sheath on a central venous catheter — CXR obtained 6 months before (above left) compared to the scout image obtained before the line study (above right) shows the tip of the catheter has migrated proximally the height of one vertebral body between the two exams. Image from the line study (below) shows contrast outlining a sheath where the catheter tip used to be.

The diagnosis was fibrin sheath where the tip of the catheter was previously.

Preschooler who is immune suppressed with a fever who had their catheter replaced 9 months ago

CT of an embolized fibrin sheath from a central venous catheter — CXR shows no evidence of pneumonia, but suggests the presence of a tubular structure in the inferior aspect of the left hilum that was not present on a prior CXR obtained before the catheter was replaced. Coronal image from a CT with contrast of the chest better demonstrates the high density tubular structure.

The diagnosis was an embolized fibrin sheath from the prior catheter which was determined by an angiogram.

School ager with a catheter that does not infuse

Line study of a leaking central venous catheter port — AP and lateral views from a line study shows contrast leaking out of and all around the port into the subcutaneous tissues with no contrast entering the catheter.

The diagnosis was a leaking central venous catheter port.

Infant with catheter that infuses but does not draw back

Line study of central venous catheter with an occluded tip — CXR from 2 weeks earlier (above) shows the tip of the catheter in appropriate position at the junction of the superior vena cava and the right atrium. Scout image from a line study (below) shows the tip of the catheter has migrated backwards in the interval and its tip now rests against the wall of the superior vena cava.

The diagnosis was occlusion of the catheter tip due to catheter migration.

Preschooler with catheter that infuses but does not draw back

Line study of a fibrin sheath on a central venous catheter — Image from a line study (above) shows a subtle dilation in the diameter of the distal catheter, which is better seen on the magnified view (below), suggesting the contrast is inside a sheath encasing the distal catheter.

The diagnosis was fibrin sheath of the catheter tip.

Preschooler with catheter that has pain with infusion and that does not draw back

Line study of a leaking central venous catheter — Image from a line study while injecting contrast shows leakage of contrast out of the proximal portion of the catheter.

The diagnosis was leaking catheter.

Teenager with catheter that infuses but does not draw back

Line study of a fibrin sheath on a central venous catheter — Scout from a line study (above) shows the tip of the catheter to be abnormally positioned in the right subclavian vein rather than in the superior vena cava. Injection of the catheter (below) shows a dilation in the diameter of the distal catheter, suggesting the contrast is inside a sheath encasing the distal catheter.

The diagnosis was fibrin sheath of the catheter tip.

School ager with catheter that infuses but does not draw back

Line study of a central venous catheter tip that has migrated out of the vessel — CXR from 1 month before (above) shows the tip of the catheter in a left-sided superior vena cava. Scout image from a line study (below left) shows the tip of the catheter has apparently migrated out of the left-sided superior vena cava. Injection of the catheter (below right) shows contrast extravasating into the mediastinum.

The diagnosis was migration of the catheter tip out of the vessel into the mediastinum.

Teenager in a motor vehicle accident with chest pain

CXR and CT and angiogram of thoracic aortic injury — CXR AP shows widened mediastinum. Axial CT with contrast of the chest shows dilated caliber of the thoracic aorta at the level of the diaphragm with surrounding mediastinal fluid (above) and normal caliber of the abdominal aorta with evidence of retrocrual hemorrhage tracking into the abdomen (below). Angiogram shows a pseudoaneurysm of the aorta at the level of the diaphragm.

The diagnosis was thoracic aortic injury.

Teenager shot by sibling with pellet gun one day ago with progressive dyspnea and chest pain

CXR and CT of pericardial effusion — CXR AP shows an enlarged cardiac silhouette, bilateral pleural effusions and radioopaque pellets in the right thorax near the hilum and left axilla. Axial and coronal CT with contrast of the chest shows a large amount of fluid in the pericardial space.

The diagnosis was traumatic pericardial effusion.

School ager with diminished femoral pulses

CXR of coarctation of aorta — CXR AP shows a 3 sign in the region of the aortic arch and bilateral rib notching.

The diagnosis was coarctation of the aorta.

School ager with dyspnea

CXR of pericardial effusion — CXR AP shows normal pulmonary vasculature and an enlarged water bottle-shaped heart.

The diagnosis was pericardial effusion. 375cc of chylous fluid were drained out of the pericardium.

Newborn with cyanosis

CXR of Ebstein anomaly — CXR AP shows decreased pulmonary vascularity and a huge box-shaped heart.

The diagnosis was Ebstein anomaly.

Preschooler with cyanosis

CXR of tetralogy of Fallot — CXR AP shows decreased pulmonary blood flow and an upturned cardiac apex resulting in a boot-shaped heart.

The diagnosis was tetralogy of Fallot.

School ager with dyspnea

CXR and angiogram of partial anomalous pulmonary venous return — CXR AP (above) shows a hypoplastic right lung, AP arterial (left) and venous (right) phases of a pulmonary artery angiogram show a right pulmonary (scimitar) vein draining into the inferior vena cava.

The diagnosis was partial anomalous pulmonary venous return.

Infant with cyanosis

CXR and angiogram of total anomalous pulmonary venous return — CXR AP (above) shows increased pulmonary blood flow and a snowman-shaped heart, AP angiogram venous phase (below) shows dilated superior vena cava on right and left vertical vein on left.

The diagnosis was total anomalous pulmonary venous return – supradiaphragmatic.

Infant with cyanosis

CXR of transposition of the great arteries — CXR AP shows increased pulmonary blood flow and an egg on a string-shaped heart.

The diagnosis was transposition of the great arteries.

Infant with tracheomalacia and concern for vascular ring

CT of calcified ligamentum arteriosum — Axial CT with contrast of the chest shows a linear crescent-shaped calcification just to the left of the trachea which appears to join the main pulmonary artery to the descending aorta. An outside institution misinterpreted this calcification as a fish bone perforating out of the esophagus and transferred the patient emergently to our institution.

Infant with a murmur

CXR of patent ductus arteriosus ductus diverticulum — CXR AP shows mild cardiomegaly and pulmonary vascular congestion along with an extra soft tissue mass just to the left of the spine near the presumed position of the ductus arteriosus.

The diagnosis was a ductus diverticulum in a patient with patent ductus arteriosus.

Infant with murmur

Angiogram of patent ductus arteriosus — AP angiogram while injecting the pulmonary artery shows simultaneous filling of the descending aorta.

The diagnosis was patent ductus arteriosus.

Newborn with a murmur

CXR AP at 1 day of life (above) and 1 year of life (below) shows interval development of cardiomegaly and pulmonary vascular congestion.

The diagnosis was patent ductus arteriosus.

Premature newborn (35 weeks) with respiratory distress

CXR of hydrops fetalis — CXR AP shows low lung volumes, large bilateral pleural effusions, and extensive body wall edema.

The diagnosis was hydrops fetalis (non-immune). The patient had a thoraco-amniotic shunt placed at 24 weeks gestational age.

Infant with respiratory distress

CXR and MRI and angiogram of left atrial aneurysm — CXR PA and lateral, coronal MRI T1WI without contrast, and a left atrial injection from an angiogram shows an extremely dilated left atrium.

The diagnosis was left atrial aneurysm.

Infant with dysphagia

UGI of left aortic arch with aberrant right subclavian artery — AP (left) and lateral (right) images from an upper GI exam shows a left sided aortic arch and a posterior indentation on the esophagus.

The diagnosis was left aortic arch with aberrant right subclavian artery.