Infant after cardiac surgery on ECMO

CT of cerebellar hemorrhage on extracorporeal membrane oxygenation (ECMO) — Axial and coronal CT without contrast of the brain shows three round mixed density lesions in the cerebellum compressing the fourth ventricle and causing hydrocephalus. The fluid-fluid levels in the lesions were felt to represent active bleeding.

The diagnosis was cerebellar hemorrhage on ECMO.

Infant with congenital heart disease on ECMO

CT of intracerebral hemorrhage in a patient on extracorporeal membrane oxygenation (ECMO) — Sagittal, coronal and axial CT without contrast of the brain shows a large, round high density lesion in the right parietal lobe.

The diagnosis was intracerebral hemorrhage on ECMO.

Newborn with congenital diaphragmatic hernia on ECMO

US of intracerebral hemorrhage in a patient on extracorporeal membrane oxygenation (ECMO) — Coronal and sagittal US of the brain shows a large, round echogenic lesion in the left parietal lobe.

The diagnosis was intracerebral hemorrhage on ECMO.

Infant who was on arterial-venous ECMO post cardiac arrest and has just been taken off of ECMO

CT of intraventricular hemorrhage, intracerebral hemorrhage, and cerebral atrophy in a patient on extracorporeal membrane oxygenation (ECMO) — Axial CT without contrast of the brain shows mixed-density fluid in the left lateral ventricle posteriorly and mixed-density fluid in the left parietal-occipital lobe. There is also diffuse prominence of the sulci and ventricular system.

The diagnosis was intraventricular hemorrhage on ECMO and intracerebral hemorrhage on ECMO and cerebral atrophy post ECMO.

Newborn who is on ECMO after cardiac surgery

US of subdural hematoma and intracerebral hemorrhage in patient on extracorporeal membrane oxygenation (ECMO) — Coronal US of the brain (below) shows echogenic material in right subdural space. Coronal and sagittal US of the brain (above) shows a right parietal round mixed echogenicity lesion.

The diagnosis was subdural hematoma on ECMO and intracerebral hemorrhage on ECMO.

Infant with congenital heart disease who was on ECMO a month ago

CT of cerebral atrophy after being on extracorporeal membrane oxygenation (ECMO) — Axial CT without contrast of the brain shows diffuse prominence of the sulci and ventricular system.

The diagnosis was cerebral atrophy post ECMO.

Newborn who did not receive a screening head ultrasound before being placed emergently on ECMO and who is not doing well on ECMO

US of Vein of Galen malformation — Coronal and sagittal US of the brain shows a high flow vascular structure in the region of the median prosencephalic vein. A bruit was subsequently noted in this area.

The diagnosis was Vein of Galen malformation, which is a contraindication to being placed on ECMO.

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.

School ager with back pain and fevers

MRI of transverse myelitis — Sagittal and axial T2 MRI of the thoracic spine shows centrally located continuous bright signal through the thoracic spinal cord that ends just above the conus medullaris.

The diagnosis was transverse myelitis.

School ager with back pain when bending over

MRI of tethered cord — Sagittal T1 (left) and T2 (right) MRI of the lumbar spine shows a low-lying conus medullaris of the spinal cord which terminates at S1. The T11/T12 vertebral body areas of low signal intensity on T1 and high signal intensity on T2 were felt to be due to aggressive Schmorl nodes as the patient had no clinical signs of infection.

The diagnosis was tethered cord.

Toddler with back pain and scoliosis

MRI of astrocytoma of spinal cord — Sagittal T1 (left), T2 (middle) and T1 with contrast (right) MRI of the thoracic spine shows an expansile lesion of the lower thoracic spinal cord that is isointense on T1, hyperintense on T2, and which enhances avidly with contrast.

The diagnosis was an astrocytoma of the spinal cord.

Preschooler who was abused

Radiographs of a healing skull fracture — Lateral radiograph of the skull initially (left) showed bilateral linear parietal lucencies coursing across the skull which are no longer seen 4 months later (right).

The diagnosis was healing skull fractures.

Infant who fell 3 feet out of bed onto a wooden floor

CT of an (not) accessory skull suture — 3D reconstruction from CT without contrast of the brain (left) shows a linear straight lucency that connects to the left lambdoid suture. Coronal CT (right) shows the same linear lucency lying under a large subgaleal hematoma.

The diagnosis was a linear skull fracture and not an accessory suture of the skull based on the soft tissue swelling associated with the linear lucency.