School ager with acute back pain and gait instability

MRI of myxopapillary ependymoma of the spinal cord — Sagittal T1 MRI without contrast (left), T2 MRI (center), and T1 MRI with contrast (right) of the lumbar spine shows an intradural extramedullary cylindrical solid mass that is arising from the filum terminale and which shows minimal enhancement. On T2 MRI (center) the mass has a triangular area of low signal intensity along its superior border (cap sign).

The diagnosis was a myxopapillary ependymoma of the spinal cord.

Teenager hit by a car while riding their bike

Radiograph and CT of secondary accessory ossification center of vertebral body mimicking cervical spine fracture — Lateral radiograph of the cervical spine (left) shows a small ossific fragment anterior and superior to the C6 vertebral body. There is no prevertebral swelling and the alignment of the cervical spine is normal. Sagittal CT without contrast of the cervical spine (right) shows that the ossific fragment is well corticated.

The diagnosis was a secondary ossification center of the cervical spine mimicking a cervical spine fracture.

School ager with ventriculoperitoneal shunt in clinic for routine followup

AXR of VP shunt migration from abdomen to chest — AXR taken 1 year ago (left) shows the VP shunt to be radiographically intact and its tip is coiled in the pelvis. AXR taken today (right) shows the VP shunt migrated out of the abdomen into the left chest and its tip is in the left costrophrenic angle.

The diagnosis was ventriculoperitoneal shunt malfunction due to shunt tip migration into the chest.

Teenager with a C5-C6 fracture dislocation after a motor vehicle accident

MRA of vertebral artery dissection after trauma — MRA with contrast of the neck in AP (left) and left oblique (middle) and right oblique (right) projections shows the right vertebral artery arises from the right subclavian artery and courses normally to where it enters the basilar artery. The left vertebral artery arises from the left subclavian artery but then is only faintly visualized along its course until it reconstitutes where it enters the basilar artery.

The diagnosis was occlusion of the left vertebral artery from C2 to C7 due to dissection of the left vertebral artery.

School ager with a ventriculoperitoneal shunt and new neck pain

Radiograph of breakage of VP shunt tubing in the neck — Lateral radiograph of the skull taken 7 years ago (above) shows the VP shunt to be intact inferior to the lucent shunt reservoir. Current lateral radiograph of the skull (below) shows a discontinuity in the ventriculoperitoneal shunt inferior to the lucent shunt reservoir due to a breakage of the shunt tubing.

The diagnosis was ventriculoperitoneal shunt malfunction in the form of a breakage of the tubing in the neck.

Teenager whose ventriculoperitoneal shunt was revised 1 month ago who now has a new headache and redness along the anterior abdominal wall.

CT of a CSFoma / cerebrospinal fluid pseudocyst in the anterior abdominal wall — Axial (above) and coronal (below) CT with contrast of the abdomen shows a round low density fluid collection in the subcutaneous tissues of the right anterior abdominal wall with inflammatory changes noted around the fluid collection. In the center of the fluid collection is a coiled ventriculoperitoneal shunt.

The diagnosis was ventriculoperitoneal shunt malfunction in the form of a CSFoma in the anterior abdominal wall due to VP shunt tip migration out of the abdomen.

School ager with a ventriculoperitoneal shunt with vomiting, diplopia, abdominal pain and newly dilated lateral ventricles

CT of CSFoma / cerebrospinal fluid pseudocyst — Axial CT with contrast of the abdomen (above) shows the VP shunt anteriorly in the abdomen coursing through a multiloculated fluid collection on the left side of the abdomen. Coronal CT (below left) shows multiple dilated loops of proximal small bowel while the sagittal CT (below right) shows the fluid collection to have at least 3 locules.

The diagnosis was a ventriculoperitoneal shunt malfunction in the form of a CSFoma.

School ager with a ventriculoperitoneal shunt who has had abdominal pain for a week and a headache for a day

CT of CSFoma / Cerebrospinal fluid pseudocyst — Axial CT without contrast of the abdomen shows a VP shunt in the anterior right abdomen that is coursing between two low density fluid collections and whose tip is in the fluid collection nearest to the midline.

The diagnosis was a ventriculoperitoneal shunt malfunction in the form of a CSFoma.

Premature newborn with apnea and bradycardia

US and MRI of choroid plexus hemorrhage — Coronal (above left) and sagittal (above right) US of the brain show the right lateral ventricle to be filled with echogenic material and to be dilated. Axial GRE MRI without contrast of the brain obtained 1 month later (below) shows dark signal representing hemosiderin in the choroid plexus of the right lateral venticle. There is no hemosiderin in the right germinal matrix.

The diagnosis was right choroid plexus hemorrhage.

Infant with a ventriculoperitoneal shunt who has projectile vomiting

CT of overshunting of the ventricular system — Axial CT without contrast of the brain show a ventriculoperitoneal shunt entering from a right parietal approach whose tip projects over the anterior horn of the right lateral ventricle. The ventricular system is completely collapsed and cannot be seen.

School ager with parasomnias and gait disturbance

MRI of diffuse midline glioma — Axial FLAIR MRI without contrast of the brain (above left) shows the pons to be enlarged and to have increased signal intensity throughout. There is also increased signal intensity in the medial aspect of the left temporal lobe. Going upwards in the brain (above right and below) the increased signal intensity is seen in the midbrain and in the left basal ganglia and thalamus.

The diagnosis was diffuse midline glioma.

Teenager with a malignant bone tumor who has headaches and vomiting

CT of brain metastasis from osteosarcoma — Axial CT without contrast of the brain shows a large dense lesion in the posterior aspect of the right cerebral hemisphere which has high density calcification along its most posterior aspect. The lesion is surrounded by low density vasogenic edema.

The diagnosis was brain metastasis in a patient with osteosarcoma.

Toddler with lethargy

MRI of atypical teratoid rhabdoid tumor — Sagittal T1 MRI without contrast of the brain (above left) shows a large, isointense, heterogenous but primarily solid mass arising in the region of the pineal gland. On axial T2 MRI without contrast (above right) the mass is also isointense but has some cysts within it. Axial DWI MRI (below left) shows diffusion restriction in the mass while axial T1 MRI with contrast (below right) shows heterogenous enhancement of the mass.

The diagnosis was atypical teratoid rhabdoid tumor.

Teenager with syncope

CT of supratentorial astrocytoma — Axial CT without contrast of the brain shows a low density mass in the region of the pineal gland and left thalamus that has a punctate area of high density within it representing either calcification or hemorrhage. The mass is having mass effect on the third ventricle resulting in obstructive hydrocephalus and transependymal flow of cerebrospinal fluid.

The diagnosis was supratentorial astrocytoma.

Teenager with left facial pain

CT of dentigerous cyst — Axial (left) and coronal (right) CT without contrast of the face show an expansile cystic lesion of the left maxilla that contains a molar tooth within it.

The diagnosis was dentigerous cyst.

Teenager who is pregnant with new onset focal neurological deficits and ataxia

MRI of acute disseminated encephalomyelitis — Axial FLAIR MRI without contrast of the brain show multiple lesions in the centrum semiovale, periventricular white matter, splenium of the corpus callosum and white matter of the parietal and occipital lobes. There was no mass effect and no diffusion restriction associated with the lesions. No contrast was given as the patient was pregnant.

The diagnosis was acute disseminated encephalomyelitis.

Preschooler with right neck swelling

CT of parapharyngeal abscess — Axial CT with contrast of the neck shows a round low density fluid collection with a thin enhancing rim in the right parapharyngeal space. The right carotid artery and right internal jugular vein are narrowed in caliber and there is mass effect on the right side of the airway.

The diagnosis was right parapharyngeal abscess.

Newborn whose mother was exposed to cytomegalovirus during pregnancy

US of cytomegalovirus encephalitis — Coronal US of the brain (above) shows large septated cysts in the germinal matrix (germinolysis) bilaterally along with multiple periventricular echogenic foci just lateral to the anterior horns of the lateral ventricles bilaterally representing periventricular calcifications. Left sagittal (below left) and right sagittal (below right) US show branching linear echogenicities in the basal ganglia respresenting lenticulostriate vasculopathy.

The diagnosis was cytomegalovirus encephalitis.

School ager with headaches

Radiograph of ventriculoperitoneal shunt malfunction due to VP shunt disconnection — Lateral radiograph of the skull obtained 3 years ago (above) shows the ventriculoperitoneal (VP) shunt tubing that courses inferiorly is connected appropriately to the radiolucent VP shunt reservoir. Lateral radiograph of the skull obtained today (below) shows interval development of increased distance between the VP shunt tubing that courses inferiorly and the radiolucent VP shunt reservoir due to interval development of a disconnection of the VP shunt tubing from the VP shunt reservoir.

The diagnosis was ventriculoperitoneal shunt malfunction due to VP shunt disconnection.

Newborn with blueberry muffin skin lesions

Radiograph of cytomegalovirus encephalitis — AP (above) and lateral (below) radiographs of the skull show bilateral thick, chunky, periventricular calcifications outlining the lateral ventricles.

The diagnosis was cytomegalovirus encephalitis.

Teenager with back pain and elevated WBC, ESR, and CRP

MRI of epidural abscess of thoracic spine — Sagittal T1 without contrast (above left), T2 (above middle) and T1 with contrast (above right) MRI of the thoracic spine shows a long extradural mass that is compressing the spinal cord and which enhances heterogeneously. Axial T2 (below left) shows bright signal intensity in the paraspinal tissues representing myositis which on T1 with contrast (below right) enhances heterogenously. The spinal cord compression from the extradural mass is also well seen on the axial images.

The diagnosis was spinal epidural abscess with a paraspinal abscess as well.

Preschooler with a nasal mass

MRI of frontonasal encephalocele — Sagittal (left) and axial (right) T2 MRI without contrast of the brain shows herniation of the frontal lobes of the brain through the nasofrontal suture.

The diagnosis was frontonasal cephalocele.

School ager with meningitis with a ventriculoperitoneal shunt that was placed a week ago who has developed a new headache today

MRI of ventriculoperitoneal shunt malfunction due to migration of the tip of the shunt out of the ventricular system. — Axial T2 MRI without contrast of the brain immediately after ventriculoperitoneal shunt placement a week ago (left) shows the tip of the VP shunt placed from a left parietal approach to be in appropriate position in the the posterior horn of the left lateral ventricle. Axial T2 MRI of the brain from today (right) shows the tip of the ventriculoperitoneal shunt to no longer be within the left lateral ventricle but to be in the brain parenchyma.

The diagnosis was ventriculoperitoneal shunt malfunction due to migration of the tip of the ventriculoperitoneal shunt out of the left lateral ventricle.

Teenager with a sore throat for several days

CT of a palatine tonsil intrastonillar abscess — Axial (above), coronal (below left) and sagittal (below right) CT with contrast of the face shows a large low density fluid collection centered in the right palatine tonsil.

The diagnosis was an intratonsillar abscess in the right palatine tonsil.

School ager with sinusitis and left eye proptosis

CT and MR of clivus chordoma — Axial (above left) CT with contrast of the face shows a large expansile mass filling the sphenoid sinus that has punctate calcifications within it and that is thinning the surrounding bone. Sagittal CT (above right) shows the mass to be arising from the top of the clivus. Coronal T2 MRI (below left) shows the mass to be heterogeneously bright and to not have any intracranial extension. Axial T1 MRI with contrast (below right) show the mass does not enhance.

The diagnosis was clivus chordoma.