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Intestinal atresia is one of the most common causes of bowel obstruction in newborns. Unfortunately, this diagnosis is often missed or delayed in extremely preterm infants because of complications of prematurity including feeding intolerance and necrotizing enterocolitis. Here we report 2 cases of jejunoileal atresia in extremely preterm infants who were diagnosed beyond 30 days of age. Case 1 had jejunoileal atresia type IIIa, whereas case 2 had type IV jejunoileal atresia complicated by short bowel syndrome. Ideally, intestinal atresia should be diagnosed as early as possible in a patient’s hospital course to attain full enteral feedings earlier and avoid prolonged hospitalization. Planned surgical intervention prior to the development of sepsis or bowel perforation is associated with better outcomes. Ultimately, this report serves as a reminder to physicians that intestinal atresia remains an important differential for infants, including preterm infants, with feeding intolerance in the first days to weeks of age.

Pelvic pain may be caused by disorders of the reproductive, urinary, or gastrointestinal systems. In the pediatric population, pelvic pain is often first evaluated with ultrasonography, with other imaging modalities reserved for further workup or specific indications. Radiologists must be aware of the findings associated with common pelvic emergencies to allow prompt diagnosis and prevention of life-threatening complications. Although the range of pelvic pathology is extensive, this pictorial review presents ultrasound examples of common nontraumatic causes of pelvic pain encountered in the pediatric population, with a brief discussion about multimodality imaging features.

Children with craniosynostosis may undergo multiple computed tomography (CT) examinations for diagnosis and post-treatment follow-up, resulting in cumulative radiation exposure. To reduce the risks associated with radiation exposure, we evaluated the compliance, radiation dose reduction and clinical image quality of a lower-dose CT protocol for pediatric craniosynostosis implemented at our institution. The standard of care at our institution was modified to replace pediatric head CT protocols with a lower-dose CT protocol utilizing 100 kV, 5 mAs and iterative reconstruction. Study-ordered, protocol-utilized and radiation-dose indices were collected for studies performed with routine pediatric brain protocols (n=22) and with the lower-dose CT protocol (n=135). Two pediatric neuroradiologists evaluated image quality in a subset (n=50) of the lower-dose CT studies by scoring visualization of cranial structures, confidence of diagnosis and the need for more radiation dose. During the 30-month period, the lower-dose CT protocol had high compliance, with 2/137 studies performed with routine brain protocols. With the lower-dose CT protocol, volume CT dose index (CTDIvol) was 1.1 mGy for all patients (0–9 years old) and effective dose ranged from 0.06 to 0.22 mSv, comparable to a 4-view skull radiography examination. CTDIvol was reduced by 98% and effective dose was reduced up to 67-fold. Confidence in diagnosing craniosynostosis was high and more radiation dose was considered unnecessary in all studies (n=50) by both radiologists. Replacing the routine pediatric brain CT protocol with a lower-dose CT craniosynostosis protocol substantially reduced radiation exposure without compromising image quality or diagnostic confidence.

Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL) are both malignancies originating in the lymphatic system and both affect children, but many features differ considerably, impacting workup and management. This paper provides consensus-based imaging recommendations for evaluation of patients with HL and NHL at diagnosis and response assessment for both interim and end of therapy (follow-up).

Neuroblastoma is the most common extracranial solid neoplasm in children. This manuscript provides consensus-based imaging recommendations for pediatric neuroblastoma patients at diagnosis and during follow-up.

The most common pediatric extragonadal pelvic cancers include germ cell tumors, sacrococcygeal teratomas, and rhabdomyosarcomas (arising from the urinary bladder, prostate, paratesticular tissues, vagina, uterus, and perineum). This manuscript describes the radiological and nuclear medicine features of these entities and provides consensus-based recommendations for the assessment at diagnosis, during and after treatment.

A resident working under the entrustable professional activity of a graduated independent coverage model must identify nonaccidental trauma and notify clinicians of this concern to facilitate potential removal of the child from harm. The resident’s role in identifying child abuse has not previously been studied. The purpose of this study was to assess radiology residents’ ability to identify radiographic imaging findings of nonaccidental trauma in a simulated call environment. The Wisdom in Diagnostic Imaging Emergent/Critical Care Radiology Simulation (WIDI SIM) is a strategically designed computer-aided simulation of an emergency imaging experience that has been rigorously tested and proven to be a reliable means for assessing resident preparedness to competently and independently cover radiology call. The residents are provided with 65 cases of varying difficulty, including normal studies. Those cases include ones that require the resident to accurately identify skeletal findings of nonaccidental trauma. The residents respond using free text that is then scored manually by faculty members utilizing a robust grading rubric. Missed cases are then categorized by observation error and/or interpretative errors. A total of 675 radiology residents were given a case of nonaccidental trauma using the WIDI simulation web-based test platform between 2014 and 2017. Child abuse was consistently underdiagnosed by radiology residents being tested for call readiness irrespective of the numbers of years in training. Correct diagnostic score averages per year ranged from 10% to 79%. In year 1, 71% of residents correctly diagnosed nonaccidental trauma with a total of 101 participants. In year 2, 130 residents participated with only 20% answering correctly. In year 3, there were 201 participants with 79% correctly diagnosing nonaccidental trauma. In year 4, only 10% of 243 residents accurately diagnosed nonaccidental trauma. Residents from various stages of training were tested. Cases used with leading histories provided, accounted for a higher correct call rate. Radiology residency programs may be deficient in teaching residents to accurately recognize and report child abuse. This deficiency has potential implications for programs where a radiology attending is not present after hours as it raises the concern that child abuse may be missed by residents taking independent call. These data further question whether graduating radiologists are competent to recognize nonaccidental trauma and demonstrates the need for additional mandatory training during radiology residency.

Childhood interstitial lung disease (chILD) is a group of lung disorders characterized by lung remodeling leading to abnormal gas exchange. ChILD is classified differently from adult interstitial lung disease and encompasses 2 broad categories: "disorders more prevalent in infancy" (2 years) and "disorders not specific to infancy" (2 years). High-resolution computed tomography can play an important role in the evaluation of chILD by narrowing the differential diagnosis and preventing unnecessary invasive procedures if typical imaging patterns are recognized. Thus, the pediatric radiologist should consider chILD in children with respiratory distress and identify the imaging patterns to suggest the diagnosis.

Intraventricular hemorrhage (IVH) is a complication of prematurity. Grades III and IV IVH lead to significant morbidity, but mounting evidence shows low-grade IVH (grades I–II) may be associated with adverse sequelae. Head ultrasounds (HUS) are used to screen infants for IVH but may miss low-grade IVH. Our study compared the results of HUS around 7 days of age to susceptibility-weighted imaging (SWI) obtained at term-corrected age in infants born at

Primary pulmonary artery sarcoma (PAS) is extremely rare in children. Nevertheless, distinguishing primary PAS from pulmonary embolism is critical to a child's survival. Primary PAS is commonly misdiagnosed as a pulmonary embolism due to similar presenting symptoms and radiographic findings. However, compared to adults, pulmonary embolism is rare in children, especially in patients who do not have predisposing factors or hypercoagulable state. We present a child with primary PAS which mimicked pulmonary embolism on presentation but eventually was resected and is doing well 5 years after resection. In the absence of predisposing factors or hypercoagulable state, solid tumors such as primary PAS should be considered when assessing a pediatric patient with presumed pulmonary embolism.

Posterior reversible encephalopathy syndrome (PRES) is classically a reversible clinical radiographic syndrome associated with predominantly posterior leukoencephalopathy on neuroimaging. Magnetic resonance imaging (MRI) in adults demonstrates almost universally reversible parietal-occipital disease. We aimed to demonstrate in a cohort of children that "atypical" distribution is expected, acutely and on follow-up.A retrospective review of children diagnosed with PRES from 2010 to 2018 at our children's hospital was performed. All had MRI at diagnoses, with over half having follow-up MRIs. Images were reviewed by a neuroradiology-trained pediatric radiologist for confirmation of findings consistent with PRES/identification of involved regions.Nineteen patients (aged zero to 18 years, 53% female) were included. Notably, two were infants. Nearly all had seizures; all had altered mental status and hypertension. Fifteen (84%) had MRI described as "atypical." Distribution of MRI findings was anatomically widespread, including nine with frontal findings. Twelve (63%) had follow-up imaging, of which approximately half remained abnormal.Pediatric PRES MRI findings were more often atypical at time of diagnosis. Vasogenic edema related to the acute phases of PRES typically resolved; however, follow-up imaging identified new volume loss in the areas affected. Two of our subjects were younger than 13 months, younger than typically described. Our series demonstrates that imaging distribution in children with PRES does not mirror the classical posterior, reversible distribution described in adults and continues the recent trend of identifying PRES in infants.

Aims: We correlate ultrasound, MRI, and clinical findings in neonates with suspected hypoxic ischemic injury. Background: Recent advances in neuroimaging have led to improved detection of subtle insults as-sociated with neurodevelopmental outcomes, beyond more historically described lesions such as large hemorrhages and hydrocephalus. Objective:: In this study, we compare cranial ultrasound to MRI for the evaluation of suspected HIE in preterm infants. Methods:: 147 premature infant patients with paired ultrasound and MRI exams were retrospectively analyzed to compare imaging finding accuracy and clinical value. Result:: We confirm that ultrasound is highly sensitive and specific for hydrocephalus, ventricular prominence, and gross structural abnormalities. Ultrasound is not a substitute for MRI in cases of small hemorrhages or white matter injury, however, certain US findings were associated with Apgar score and MRI sequelae of HIE. Conclusion:: Choosing between ultrasound and MRI for preterm neonates at risk for intracranial ab-normalities based on their strengths can reduce cost and maximize clinical utility. MRI provides a highly sensitive identification of subtle brain injury, yet ultrasound is correlated with the peripartum clinical picture as measured by Apgar score.

Neuroprognostication in neonates with neonatal encephalopathy (NE) may be enhanced by early serial measurement of a panel of four brain-specific biomarkers.To evaluate serum biomarkers, 40 NE samples and 37 healthy neonates from a biorepository were analyzed. Blood samples were collected at 0-6, 12, 24, 48, and 96 h of life. MRI provided a short-term measure of injury. Long-term outcomes included death or a Bayley III score at 17-24 months of age.Glial fibrillary acidic protein (GFAP), ubiquitin c-terminal hydrolase-L1 (UCH-L1), and Tau peaked at 0-6 h of life, while neurofilament light chain (NFL) peaked at 96 h of life. These four marker concentrations at 96 h of life differentiated moderate/severe from none/mild brain injury by MRI, while GFAP and Tau showed early discrimination. For long-term outcomes, GFAP, NFL, Tau, and UCH-L1 could differentiate a poor outcome vs good outcome as early as 0-6 h of life, depending on the Bayley domain, and a combination of the four markers enhanced the sensitivity and specificity. Machine learning trajectory analyses identified upward trajectory patients with a high concordance to poor outcomes.GFAP, NFL, Tau, and UCH-L1 may be of neuroprognostic significance after NE.Serial measurements of GFAP, NFL, Tau, and UCH-L1 show promise in aiding the bedside clinician in making treatment decisions in neonatal encephalopathy. The panel of four neuroproteins increased the ability to predict neurodevelopmental outcomes. The study utilized a trajectory analysis that enabled predictive modeling. A panel approach provides the bedside clinician with objective data to individualize care. This study provides the foundation to develop a point of care device in the future.

Citation:Joseph N, Rajderkar D, Baker D, Prabhakaran S. Arnold-Chiari malformation: an uncommon etiology for a brief resolved, unexplained event in an infant. J Clin Sleep Med. 2020;16(11):1983–1984.

OBJECTIVE: To evaluate whether extremely low gestational age neonates (ELGANs) randomized to erythropoietin have better or worse kidney-related outcomes during hospitalization and at 22–26 months corrected gestational age (cGA) compared with those randomized to placebo. STUDY DESIGN: We performed an ancillary study to a multicenter double-blind, placebo-controlled randomized clinical trial of erythropoietin in ELGANs. RESULTS: The prevalence of severe (stage 2 or 3) acute kidney injury (AKI) was 18.2%. We did not find a statistically significant difference between those randomized to erythropoietin vs. placebo for in-hospital primary (severe AKI) or secondary outcomes (any AKI and serum creatinine [SCr]/ cystatin C values at days 0, 7, 9 and 14). At 22–26 months cGA, 16% of the cohort had an estimated glomerular filtration rate (eGFR) 30 mg/g, 23% had a systolic blood pressure (SBP) >95(th) percentile for age, and 40% had a diastolic blood pressure (DBP) >95(th) percentile for age. SBP >90(th) percentile occurred less often among recipients of erythropoietin (p95(th) percentile or DBP >90(th) or >95(th) percentiles. CONCLUSIONS: ELGANs have high rates of in-hospital AKI and kidney-related problems at 22–26 months cGA. Recombinant erythropoietin (rhEpo) may protect ELGANs against long-term elevated SBP, but does not appear to protect from AKI, low eGFR, albuminuria or elevated DBP at 22–26 months cGA.

Multimodal CT scans, including non-contrast CT, CT perfusion, and CT angiography, are widely used in acute stroke diagnosis and therapeutic planning. While each imaging modality has its advantage in brain cross-sectional feature visualizations, the varying image resolution of different modalities hinders the ability of the radiologist to discern consistent but subtle suspicious findings. Besides, higher image quality requires a high radiation dose, leading to increases in health risks such as cataract formation and cancer induction. In this work, we propose a deep learning-based method Transfer-GAN that utilizes generative adversarial networks and transfer learning to improve multimodal CT image resolution and to lower the necessary radiation exposure. Through extensive experiments, we demonstrate that transfer learning from multimodal CT provides substantial visualization and quantity enhancement compare to the training without learning the prior knowledge.

PURPOSE: To assess various computational phantom alignment techniques within Monte Carlo radiation transport models of pediatric fluoroscopically-guided cardiac interventional studies. METHODS: Logfiles, including all procedure radiation and machine data, were extracted from a Toshiba infinix-I unit in the University of Florida Pediatric Catheterization Laboratory for a cohort of 10 patients. Two different alignment methods were then tested against a ground-truth standard based upon identification of a unique anatomic reference point within images co-registered to specific irradiation events within each procedure. The first alignment method required measurement of the distance from the edge of the exam table to the top of the patient’s head (table alignment method). The second alignment method fixed the anatomic reference point to be the geometric center of the heart muscle, as all 10 studies were cardiac in nature. Monte Carlo radiation transport simulations were performed for each patient and intervention using morphometry-matched hybrid computational phantoms for the reference and two tested alignment methods. For each combination, absorbed doses were computed for 28 organs and root mean square organ doses were assessed and compared across the alignment methods. RESULTS: The percent error in root mean square organ dose ranged from −57% to +41% for the table alignment method, and from −27% to +22% for the heart geometric centroid alignment method. Absorbed doses to specific organs such as the heart and lungs demonstrated higher accuracy in the heart geometric centroid alignment method, with average percent errors of 10% and 1.4%, respectively, compared to average percent errors of −32% and 24%, respectively, using the table alignment method. CONCLUSIONS: Of the two phantom alignment methods investigated in this study, the use of an anatomical reference point – in this case the geometric centroid of the heart – provided a reliable method for radiation transport simulations of organ dose in pediatric interventional cardiac studies. This alignment method provides the added benefit of requiring no physician input, making retrospective calculations possible. Moving forward, additional anatomical reference methods can be tested to assess the reliability of anatomical reference points beyond cardiac centered procedures.

The allegation of child abuse, or non-accidental trauma, is very serious and can have a devastating impact on children and their families. However, the lack of recognition of injuries resulting from abusive incidents can be equally detrimental. When a child presents to the emergency facility with a suspicious injury it is of the utmost importance that a well-documented medical history be obtained. We present a case of a 3-day old infant sent to the pediatric ER after the pediatrician noted bruising over the right shoulder and clavicle. A subsequent skeletal survey performed demonstrated a mildly depressed skull fracture and an overriding displaced right clavicular fracture raising a concern of non-accidental trauma (NAT). Upon further review of the patient's history, it was noted that the mother was involved in a high- speed motor vehicle collision on the day of delivery. Review of the mother's body trauma computed tomography (CT) scan revealed that the injuries were, in fact, sustained in utero and obviating the need for further NAT work up and investigation. This case demonstrates forensic use of radiologic images to establish a diagnosis of an accidental trauma.

Metanephric adenofibroma is a rare pediatric renal tumor, which should be considered in cases of solid renal lesions that mimic Wilms tumor on both imaging and histology. We present a case of an incidentally found left renal lesion on a trauma computed tomography scan in a 5-year-old male patient. The patient underwent total nephrectomy, and the diagnosis of metanephric adenofibroma was made on histology. Radiologists should consider this entity in the differential for an incidentally found solitary renal mass in a pediatric patient. Prompting the pathologic diagnosis of this entity can spare patients from unnecessary chemotherapy and allow for nephron-sparing surgery. Keywords: Pediatric renal mass, Wilms, Benign mass

Langerhans cell histiocytosis (LCH) is a disorder of the monocyte-macrophage system that can be unifocal or systemic. Here, we present a pediatric case who initially presented with osseous LCH but again presented 6 years later emergently with cerebellar symptoms, cerebellar mass and obstructive hydrocephalus. Patient underwent biopsy of the cerebellum which was path proven intracranial LCH.

In this article, we discuss pediatric cervical spine anatomy and congenital variants that may mimic upper cervical spinal injuries. In addition, we identify the imaging modalities and imaging utilization to evaluate cervical spine trauma. We review the role of plain radiographs and CT scans for bony

Intrapartum uterine rupture is a life-threating and rare complication of pregnancy which seldom occurs in the second trimester. Typically, the diagnosis is made using ultrasound; however, magnetic resonance imaging can provide certain advantages in the emergent setting. We present a unique case of a posterior uterine rupture confirmed by magnetic resonance imaging involving the unscarred posterior uterine wall in a 20-year-old gravid female with two previous cesarean-sections.

Objective Due to logistical constraints, physicians traditionally delay diagnostic imaging for neonatal hypoxic-ischemic encephalopathy (HIE) until the neonate has completed all 72 hours of therapeutic hypothermia and rewarming. In some cases, neonates may require neuroimaging before 72 hours has passed. Study Design We present a case in which an MRI was acquired during active hypothermia. Results Upon return to the NICU, Baby X's temperature probe read 33.6 degrees, indicating that hypothermia was likely maintained at the target temperature. Conclusion Active hypothermia is possible during MRI.

Introduction PTLD is the most frequent malignancy following SOT in children and the second most common SOT complication in adults. However, factors determining outcomes in children are poorly understood due to its relative rarity. Methods This study was performed at the University of Florida. Univariate and multivariate analyses were used to identify prognostic factors in pediatric patients diagnosed with PTLD. Results We reviewed records of 54 pediatric (younger than 18 years old at diagnosis) patients diagnosed with PTLD from 1994 to 2017. The median follow-up was 28.8 months. The estimated 5-year survival rate was 87.6% (95% CI 74.3-94.2%). Univariate analysis showed that organ transplanted (specifically heart transplant), poor response to initial treatment, allograft rejection, and low Karnofsky score were statistically significant for negative prognostic factors in determining survival. Multivariate analysis determined progression in response to initial treatment and presence of allograft rejection as statistically significant prognostic factors affecting overall survival. We found no statistically significant impact of EBV serological status on PTLD prognosis. Conclusions Disease progression and allograft rejection were strong negative prognostic indicators in our study cohort. Close attention to graft status and development of therapies that protect the graft from rejection while bolstering anti-EBV immunity will be essential to further improving PTLD outcomes in children.

Childhood interstitial lung disease (chILD) consists of a large, heterogeneous group of individually rare disorders. chILD demonstrates major differences in disease etiology, natural history, and management when compared with the adult group. It occurs primarily secondary to an underlying developmental or genetic abnormality affecting the growth and maturity of the pediatric lung. They present with different clinical, radiologic, and pathologic features. In this pictorial review article, we will divide chILD into those more prevalent in infancy and those not specific to infancy. We will use a case based approach to discuss relevant imaging findings including modalities such as radiograph and computed tomography in a wide variety of pathologies.

Congenital pulmonary artery anomalies are infrequent but given improved prenatal diagnosis and care, and neonatal surgical advances, over the past two decades are not uncommonly encountered by cardiothoracic imagers. An understanding of their etiology, classifications, associated anomalies, and surgical management can be helpful to avoid under or overdiagnosis. Timely diagnosis assisted by familiarity with imaging findings across modalities and recognition of surgical findings allows for medical management and surgical planning for these patients, with more patients reaching adulthood than ever before.

Pectus excavatum is a common chest wall deformity with no known cause. A common hypothesis is that in patients with pectus excavatum, there is an overgrowth of costal cartilage relative to healthy individuals.We obtained radiological curvilinear three-dimensional measurements of the fourth to eighth costal cartilage and associated ribs in 16 patients with pectus excavatum and 16 age- and gender-matched controls between the ages of 6 and 32 y. An analysis of variance was used to compare bone length, cartilage length, and their ratios between patients and controls.Relative to bone length, patients with pectus excavatum overall had shorter costal cartilage lengths (P 0.001), especially on the left side (P 0.05). We were unable to localize this observation to specific ribs during post hoc analysis.This is the first study to empirically test the overgrowth hypothesis of pectus excavatum for ribs 4 through 8. Although we and others have found no evidence to support this hypothesis, we surprisingly found the alternate hypothesis to be true: patients with pectus excavatum tend to have shorter costal cartilages. Future studies should expand on these results with larger sample sizes and consider volumetric measurements longitudinally during thoracic development.

Thousands of patients with hydrocephalus are treated successfully with ventriculoperitoneal shunts. Ventriculoperitoneal shunts are known to have high malfunction rates, most of which are owing to mechanical causes. When shunt malfunction is suspected, shunt series are often performed to evaluate the mechanical causes of malfunction. These initial radiographs have proven critical in guiding subsequent management. This article is designed to review the various causes of shunt malfunction that can be diagnosed with radiographs.

A previously healthy 10-year-old female presented to a local emergency department following three days of nausea and vomiting diagnosed with a solid pseudopapillary tumor. Solid pseudopapillary neoplasms are a rare form of pancreatic cystic neoplasm that typically presents in young females in their 20–30s and are very rare in children. These neoplasms often present as an asymptomatic tumor found on incidental imaging. When symptomatic they most commonly present with abdominal pain and can also cause a palpable abdominal mass, weight loss, gastrointestinal obstruction, and nausea and vomiting. Timely diagnosis of this rare neoplasm is very important because complete resection of the tumor is the definitive treatment and leads to an excellent long-term survival.