Paeds Flashcards
When does clincial concern beign for scoliosis?
lateral curvature exceeds 10 degrees
pain
not fully corrected
what type of radiographs for scoliosis
standing PA and lateral
all of the iliac crests included
what is the Risser staging?
assess skeletal maturity on the iliac crests
what can cause scoliosis that should be reviewed for?
malignancny and abscess paraspinally.
MRi in scoliosis is reserved for who?
pain
neuro deficit
MRI in scoliosis
what protocol
Sag T1 and T2 of whole spine
Coronal T2 to look at bones
Axial of abnormal area and the conus (for tethered cord)
Scoliosis what angle is used?
Cobb angle
Most common type of scoliosis
Idiopathic
Other types of scoliosis
Idiopathic
nerumuscula
congenital
developmental
tumour
miscellaneous
Congenital Vertebral Anomalies:Types of Anomalies
Unilateral.
Bilateral (balanced defect)
Incarcerated
associated abnormalities with congenital vertebral anomalies
urinary tract
congenital heart disease
undescended scalulae
diastematomyelia
which scoliotic defect causes loss of longitudinal growth?
hemivertebrae
what are the management options for scoliosis?v
Observe, if no disability and not beyond 25 degrees.
Bracing - for growing child, prevent progression
Surgery - fusion - hold progression
What time frame of onset in scolioisis is a definite indication for MRI
eary onset (<10yrs)
Child back pain - reasons to CT
?osseous tumour
sondylolysis
history of truama
focal back pain
Spondylolysis - what is it?
Spondylolysis is a defect in the pars interarticularis,
difference between facet joint and spondylolyis
facet smooth
spndylo rough
MRI changes in a Pars defect
On MRI, there will be altered signal in the pars interarticularis (high signal on T2-weighted images and low signal on T1-weighted images) in pars defect.
Discitis is characterised by …..
disc space narrowing with end-plate irregularity and sclerosis.
may take two weeks to show on radiographs
OSteoid osteoma appears as what on radiographs/v
central lucent nidus surrounded by sclerotic bone
cause of back pain and is typically worse at night, exacerbated by alcohol and relieved by non-steroidal anti-inflammatory drugs
OSteoid osteoma
Osteoblastoma is what kind of tumour
what does it produce
is a benign osseous tumour that produces osteoid and wormian bone.
slow growing
Appearance of Osteoblastoma on MRI
low T1 and intermediate to high T2.
Signal void on all sequences related to matrix calcification
what can Langerhand cells histiocytosis cause in the spine
complete collapse of the vertebral body
Metastatic disease in the spine can be caused by what conditions in paeds
lymphoma, leukaemia, neuroblastoma, Ewing’s sarcoma and rhabdomyosarcoma.
Kyphosis with anterior wedging and end-plate irregularity are typical findings in XXXX
Scheuermann’s disease.
In infancy, torticollis is usually due to a
benign sternomastoid tumour (fibromatosis colli)
rotatory atlantoaxial fixation - what is it?
C1 is rotated and fixed.
Out of alignment, not symmetrical
atlantoaxial dislocation - what is it
complete disruptin of the articular mechanism.
likely truama but also congential segmentation of spine.
Torticollis and atlantoaxial subluxation may be secondary to retropharyngeal infection.
what is the syndrome called
This is known as Griesel’s syndrome.
Sandifer syndrome
Severe gastro-oesophageal reflux can cause abnormal posturing of the head and neck which may resemble torticollis.
Note the herniation of elongated cerebellar tonsils through the foramen magnum - what could be the problem?
Chiari 1 malformation
The hallmark of DDH is
acetabular dysplasia resulting in a shallow or dysmorphic socket for the femoral head
Is DDH present at birth?
No, only after first few months
early DDH treatment
abduction device
short treatment (2-4 months)
Normal or near normal hip likely
late DDH diagnosis considered when
4 months
complications of DDH
Osteoarthritis
Ortolani ad Barlow manoevres - WHEN?
DONE AT 6 WEEKS and birth
Ortolani and Barlow are done when
birth and 6 weeks
Ortolani and Barlow - which is which
Ortolani isto reduce the hip
what imaging is used for DDH based on patients age?
under 1 - US
over 1 - CT or MRI
Need to see the floor of acetabulum and cant if ossified
DDH US need to show
Labrum, coronol plane
lower limb of the ilium
DDH Graf types of hip
4 types
T1 and 2 - centred hips
Types 3 and 4, decentred
biggest cause of intusseption
idiopathic
complications of intussepction
obstruction and ischmaeia
intussuseption associations
coeliac
cystic fibrosis
why does intusseption present with rectal bleeding?
meckels
underlying causes of intussuseption?
meckels
duplication
polyp or lymphoma
plain film in intusseption?
can appear normal
What blood vessels to chekc in US scan of intusseption?
Always check the superior mesenteric artery (SMA)/superior mesenteric vein (SMV) orientation, if you can, during your ultrasound.
Factors contributing to the likely successful reduciton of intussuseptio
acute onset and scanning
Vascular flow within the intussuseptio
which side of intussuseption is harder to reduce
left sided more difficult
prior to intersusseption suflation - what needs to be checked locally?
surgeons and anaesthetist available to do procedure and happy to
IV access is a must
insufflation pressures
80 to 120mmHg
conditions that may cause intussuseption>
meckels
peutz jeghers
Henoch- Schoenlein
Cuases of acute abdo pain are categorised as what
surgical and non surgical
examples of non surgical casues of abdo pain
Gastroenteritis
Diabetic Ketoacidosis
Pneumonia / pharyngitis
aim of imaging in abdominal pain?
to work out who needs abx or surgery?
age related diagnosis - Nenonatal abdominal pain
Intestinal obstruction
Malrotation with midgut volvulus
Meconium ileus
Hirschsprung’s disease
Bowel atresia
Necrotising enterocolitis
age related diagnosis - Toddler
abdominal pain
Malrotation +/- volvulus
Intussusception
Incarcerated hernia
Gastroenteritis
Haemolytic uraemic syndrome
Meckel’s diverticulum
Urinary tract infection
Constipation
age related diagnosis - Older school aged child
abdominal pain
Appendicitis
Mesenteric adenitis
Bowel obstruction
Inflammatory bowel disease
Henoch-Schönlein purpura
Urinary tract infection and obstruction
Cholecystitis and pancreatitis
Constipation
Primary peritonitis
Gynaecological causes
Non-abdominal causes such as pneumonia and diabetic ketoacidosis
Until proven otherwise bilious vomitting is considered as WHAT
until proven others
Surgical cause
Abdo pain and very high fevers (over 38.5) consider what
mesenteric adenitis over appendicitis
when should we do an abdominal radiograph in acute abdo pain
acute obstruction
renal colic
perforation
unclear following initial assessment
is intestinal perforation more or less common at neonatal age
more common.
as older child will have clear peritonitis with it
Psoas shadows and properitoneal fat stripes
their absence suggests
indicate retroperitoneal inflammation, acute appendicitis
How is obstruction classified
mechanical or functional
normal size of appendix
less than 6mm
appendicitis Peri appendicular fluid may be a sign of
imminent perforation.
what happens to the mesentry in mesenteric adentiis
very vascular
Meckel’s diverticulum is a true diverticulum arising from the
anti-mesenteric border of the distal ileum
Meckel’s diverticulum rule of 2’s
It occurs in 2% of the population
It is two times more common in males
It is 2 inches long
It rises 2 feet from ileocaecal valve
2% become symptomatic
Most patients present within the first 2 years of life
Two out of three cases have ectopic gastric or pancreatic tissue
most common complication from Meckel’s diverticulum is
GI haemorrhage
Meckels on US
incompressible, blind-ending tubular structure with hypervascularity on Doppler
Indications for a cranial USS
Prematurity
low birth weight
birth asphyxia
clotting disorders
seizures
congenital abnormality
large or small head circumference
Cranial US reviews what structures
Parenchyma
CSF spaces
cranial US - grey matter is hypo or hyper
hypo echoic
Over what times of gestation does sulci form ?
Sulcal development begins during the 5th month of gestation. Primary sulci are present by the 7th month. In the 8th and 9th months, there is bending and branching of the 1° sulci with the appearance of 2° and 3° sulci.
Brainstem echogenicity
anterior is echogenic
psoterior
what are the US cranial views needed
frontal lobes and then horns
munro and 3rd ventricle
bodies then trigone of lateral ventricles
occipital lobes
then sagittal - mid, lat ventricles then extreme lateral ventricles
what level is the US cranial ventricular index measures
level of foramen munro
if there is echogenic anterior to WHAT consider haemorrhage on paediatric ultrasound
Munro
In a term infant, a normal RI is
greater than 0.6.
UIS appearance of cerebral oedema
slit like ventricles
increased parenchymal echogenicity, poor definition of sulci and gyri, and decreased vascular pulsations.
cavum septum pallucidem at birth
normal finding.
50% of babies it.
Bilateral choroid plexus cysts indicate …..
trisomy
Pre term or term
Periventricular blush and asymmetry of lateral ventricles
Pre term more likely
most common US cranial pre term pathologies
intraventricular-germinal matrix haemorrhage (GMH)
periventricular leukomalacia (PVL)
GMH is also called
subependymal haemorrhage
neonates with IVH-GMH subsequently develop an associated parenchymal flare due to
venous infarction
What are the sequelae of Germinal matrix haemorrhage / IVH in the preterm neonate?
Hydrocephalus
Ventriculitis
Porencephalic cyst
Trapped fourth ventricle
Spinal canal dilatation
post hypoxic ischaemic neonatal brain injury how long for cysts to be made `
2 - 4 weeks
At what age in pre term does the water shed area move to the periphery of the brain
36 weeks
hydrocephalus vs dilatation from atrophy
hydrocaphalus features
temporal horns also dilated
4th centricle dilatation
cortical sulci effacement
raised iCP
causes of hydrocephalus
Congenital malformations, such as vein of Galen malformation or aqueduct stenosis
Rarely neoplasia, for example posterior fossa tumours or choroid plexus papilloma
Infection
Benign infantile hydrocephalus
Chiari malformation
Meningomyelocoele
causes of fetus meningioencephalitis infection
Cytomegalovirus (CMV)
Toxoplasma gondii
Rubella virus
Herpes simplex (HSV) type 2 virus (known as toxoplasmosis/rubella/cytomegalovirus/herpes simplex (TORCH) complex)
common infections for neonatal meningitis are…..
E Coli and Group B strep
or HiB for 2 months to 2 years
Congenital malformations that
Errors in histogenesis (development of tissues)
Vein of Galen malformation
Tuberous sclerosis
Sturge-Weber syndrome
Neurofibromatosis
Congenital malformations
Errors in organogenesis
Neural tube closure (3-4 weeks gestational age)
Diverticulation (5-10 weeks gestational age)
Neuronal proliferation (2-6 months gestational age)
Sulcation and migration (2-5 months gestational age)
Myelination (7 months in utero - 2 years)
Congenital malformations
Errors in organogenesis of brain
Neural tube closure (3-4 weeks gestational age)
Diverticulation (5-10 weeks gestational age)
Neuronal proliferation (2-6 months gestational age)
Sulcation and migration (2-5 months gestational age)
Myelination (7 months in utero - 2 years)
Features of Dandy walker complex
Large fluid filled posterior fossa cyst (dilated fourth ventricle)
Small or absent cerebellar vermis
Small cerebellar hemispheres displaced superiorly
Elevated tentorium
Lateral ventricles and third ventricle may be dilated
What are the common palpable masses in an neonate
Ovarian mass
hydronephrosis
what are the common cuases of a palpable abdominal mas in an infant
Pyloric tumour
constipation
hydronephrosis
intussusception
haptosplenomegaly
young female - abdo mass
first line investigation is
Ultrasound
paediatric hydronephrosis - next imaging step?
Bladder outlet obstruction must be excluded. The next stage is to proceed to a micturating cystourethrogram (MCUG) (after antibiotics).
Renal tumours
Wilms tumour
retroperitoneal adrenal neuroblastoma
pelvic rhabdomyosarcoma
Liver tumours
hepatoblastoma
HCC
the developing GI tract is divided into three parts: when
3 weeks
The ventral aspect of the foregut gives rise to the WHAT and its dorsal to the oesophagus.
respiratory primordium
Skin, central and peripheral nervous system is what embryonic layer
ECTOderm
GI and repsiraotry lining is what embryology layer
Endoderm
think endoscopic
Muskuloskeletal
mesoderm
diffrence between an enteric cyst and neuroenteric cyst
neuroenteric cyst involved the ectoderm
enteric only the endoderm
formes frustes TOF vs duplications
duplications are always posterior
TOF
Oesophageal lung
In this condition, the right main bronchus arises from the distal oesophagus. Patients present with recurrent chest infections.
double bubble sign
duodenal atresia
what are the VACTERL associations
V: vertebral defects
A: anal atresia
C: cardiac defects
TE: tracheoesophageal fistula
R: renal anomalies
L: limb abnormalities
what GI defects are ax with Downs syndrome
Duodenal atresia or stenosis
Annular pancreas
VACTERL
Hirschsprung’s disease
Small bowel malrotation
twisted ribbon sign
twisting of the mesentry around the SMA
Conditions with malrotation
exomphalos or gastroschisis
Congenital diaphragmatic hernia (often)
Hirshsprungs
Short vs long segment
Short - dilated normal bowel. Coned abnormal bowel .
Long - long affected length. Rare
inferior one-third of the anal canal is derived from the X
proctodaeum.
inferior one-third rectum is supplied by the:
Inferior rectal arteries
Branches of the pudendal artery
Imperforate anus and anorectal anomalies which include:
Anal atresia
Anal stenosis
Rectal atresia
Ectopic anus (‘fistula’)
Proliferation with hypertrophy of the mesenteric fat (fat wrapping) is a finding associated with
with inflamed bowel
Mucosal oedema, avid mucosal enhancement, mesenteric oedema and enhancing reactive lymph nodes are more commonly seen in ACUTE OR CHRONIC INFLAMMATION
ACUTE
Causes of abnormally shaped vertebral bodies
Conditions with normal bone density
Deficient ossification of vertebral bodies (hypoplasia with anterior wedging/kyphosis, coronal or sagittal clefting)
Hypoplastic peg
Deficient ossification of pedicles
Genetic, structural, congenital and acquired abnormalities of shape
Causes of abnormally shaped vertebral bodies include:
Conditions with reduced bone density and vertebral body collapse
Osteoporosis
Fracture
Odontoid hypoplasia is seen in
Achondroplasia
Diastrophic dysplasia
Metaphyseal chondrodysplasia (type McKusick)
Kniest dysplasia
Metatropic dysplasia
Mucolipidoses
Mucopolysaccharidoses (MPS)
Pseudoachondroplasia
Spondyloepiphyseal dysplasia congenita
Absent ossification of vertebral bodies
Achondrogenesis type I
Atelosteogenesis
Dyssegmental dysplasia
Hypochondrogenesis
Hypophosphatasia
Opsismodysplasia
Cervical kyphosis results from hypoplasia of the anterior parts of one or several vertebral bodies
seen in which conditions
telosteogenesis (Fig 1)
Campomelic dysplasia (Fig 2)
Chondrodysplasia punctata
Diastrophic dysplasia (Fig 3)
Kniest dysplasia
Larsen syndrome
Spondyloepiphyseal dysplasia congenita
Campomelic dysplasia means
(bent limbs)
Paeds vertebral body shape
Beaks:
MPS type IV (Morquio)
Paeds vertebral body shape
Bullets:
achondroplasia
Paeds vertebral body shape
Codfish:
osteogenesis imperfecta
Paeds vertebral body shape
Diamonds:
metatropic dysplasia
Paeds vertebral body shape
Hooks:
Hurler syndrome (MPS type IH)
Paeds vertebral body shape
Pears:
spondyloepiphyseal dysplasia congenita (SEDC)
Paeds vertebral body shape
Scalloped:
MPS, achondroplasia, neurofibromatosis
Paeds vertebral body shape
Wafers:
thanatophoric dysplasia
Ataxia and absent reflexes are the clinical signs of ….
Guillain–Barré syndrome
a solid tumour of the spine in paeds MRI will look like
hyperintense on T2W
hypointense on T1W imaging
Is a well-defined mass enhances gadolinium
associated with a tumoral cyst
May have a central area of necrosis, which has the MR characteristics of cyst formation
MRI haemorrhage does what intensities over time
Within several days of the haemorrhage, the state of oxygenation will change to deoxyhaemoglobin (which is hypointense on T1W and T2W imaging), and further to intracellular methaemoglobin, and the area of haemorrhage will become hyperintense on T1W and hypointense on T2W imaging.
Axial T1W imaging shows a flow void within the cord indicating the presence of a
blood vessel and an arteriovenous malformation.
Intramedullary masses have the following radiological features:
Enlargement of the spinal cord in all three planes
The spinal cord above and below the mass is positioned normally within the bony spinal canal
The margins of the mass may be well defined or poorly defined
Extramedullary masses have the following radiological features
The margins of the mass are always well defined
Small masses can be seen separated from the cord by CSF
Large masses will obliterate the space between the mass and the cord
- IntramedullarY - TUMOURS
pilocytic astrocytoma, ependymoma and ganglioglioma
Extramedullary CORD TUMOURS
neurofibroma, schwannoma and disseminated leptomeningeal metastases
The MR features of a discitis are
the same as in an adult. The disc space will be narrow and the disc will have both prolonged T2 (hyperintense on T2W images) and T1 (hypointense on T1W images) signals and will enhance
STAGE age t1 t2
DRAW THE TABLE FOR THESE ACROSS
HYPERACUTE
ACUTE
EARLY SUBACUTE
LATE SUBACUTE
CHRONIC
Hyperacute <24 h Isointense Mildly hyperintense
Acute 1-3 d Mildly hypointense Hypointense
Early subacute 3-7 d Hyperintense Hypointense
Late subacute 7-14 d Hyperintense Hyperintense
Chronic >14 d Hypointense Hypointense
ASSOCATION of NG2 and intramedullary tumours
pilocytic astrocytomas of the cord are seen in children with NF1 and ependymomas in children with NF
Thoracic, lumbar locations; conus (especially myxopapillary)
Centra
Well-demarcated
Potential hemosiderin ‘cap sign’ on T2
Can have drop metastases
diagnosis
ependymoma
Cervicomedullary junction
Eccentric
Can calcify
Heterogeneous T1
Little peritumoral oedema
diagnosis
gnagliiogllioma
Well circumscribed
Cyst/slow voids
Can be haemorrhagic
Vigorous enhancement
diagnosis
haemangioblastoma
Cervicothoracic junction
Eccentric
Cystic with enhancing nodule/infiltrative with irregular enhancement and ill-defined margins
diagnosis
astrocytoma
round fusiform well-defined masses that can expand out of the neural foramen giving them a dumbbell appearance. They are usually isointense on TI and hyperintense on T2 with homogeneous enhancement post-contrast.
neurofibromas
when does malrotation presentations normally occur
first month of life
bile stained vomitting in a neonate is what until proven otherwsie
malrotation
what does an abdominal radiograph offer in malrotation
nothing
does US exclude malrotation?
no
thought the duodenum passing behind the sma is highly reassuring
what is the relationship of the mesentry and DJ flexure to consider malrotation
should swing under. The DJ flexure should be at the same level as the duodenal cap
commonest gastrointestinal emergency in neonates.
NEC
when does NEC occur
second or third week of life
what happens to bowel wall blood flow in NEC
more and more blood flow until sloughing leaving only the serosa intact
ischaemia wall becomes thin walled and no blood
in NEC - what signs are there to look for
Pneumotosis intestinalis
portal venous gas
free intraperitoneal gas
in neonatal abdo xr - bowel width can be compared to
widtth of L1
how to differentiate intramural vs intraluminal gas in NEC on US
intramural gas is all the way around the bowel.
`
intraluminal rises to the top
if on fluoro there is uncertainty of level or position of DJ flexure what can you do later?
abdo film to see if the caecum is seen in the righ tplace
newborn with lung mass
differentials include
Congenital cystic adenomatoid malformation
Bronchopulmonary sequestration
Congenital diaphragmatic hernia
Lung filled with retained amniotic fluid secondary to a congenital lobar emphysema or bronchial atresia
how to differentiate congenital cystic adnematoid malformation in the lung from sequestration
blood supply
Sequestration from the systemic
Also cysts in CCAM.
what is Transient Respiratory Distress of the Newborn
delay in normal physiological clearance
typical of meconium aspiration syndrome chest radiograph
Normal or slightly overinflated lungs
Extensive patchy lung shadowing with some peripheral overinflation
Often cardiac enlargement due to concomitant myocardial ischaemia
differential for meconium aspiration
amniotic fluid apsiraiton
this clears more quickly and no complications such as pulmonary hypertension and secondary infection
Overinflated lungs
Course reticular shadowing
‘Barrel’ shaped chest
chest radiograph
bronchopulmonary dysplasia
patent ductus arteriosus causes what kind of shunting
left to righ
why can the patent ductus arteriosus remain open in hypoxia ?
hypoxia which has led to higher pulmonary artery pressures due to failure of pulmonary artery resistance to fall after delivery
Well-recognised but rare complication of surfactant treatment (due to capillary engorgement)
pulmonary haemorrhage
features of pulmonary hypoplasia
Small volume chest
Hazy lungs due to associated pulmonary oedema
Clinical difficulty in ventilating (high pressures required) and poor oxygenation
Common causes of pulmonary hypoplasia include
Oligohydramnios in pregnancy
Lung compression, e.g. by tumour or diaphragmatic hernia or effusion or large heart
Thoracic cage compression (e.g. bone dysplasia) or muscular disease (e.g. dystrophy)
Unilateral Pulmonary Hypoplasia/Agenesis
features
Often asymptomatic
Can be discovered incidentally
May show associated rib or vertebral anomalies
association with oesophageal atresia and tracheal abnormalities
More serious if aplasia is right-sided (due to severity of associated cardiac anomalies)
Features of pulmonary lymphangiectasia
Very rare condition
Intractable respiratory distress with cyanosis
Survival beyond neonatal period unlikely
May be isolated or associated with generalised lymphatic problems
Radiological appearances are a combination of distended lymphatics leading to streaky lung and chylous pleural effusion
Can be associated with Noonan’s syndrome and Turner’s syndrome
right to left shunting through the patent ductus arteriosus - radiograph features
Right to left shunting
Poor lung vessel visualisation
Right heart enlargement (due to raised right heart pressures, tricuspid incompetence and myocardial dysfunction)
at what time can bronchopulmonray dysplasia be diagnosed
at least 28 days of age
caused by surfactant deficinecy, prolonged ventilation and prematurity
what are the surgical causes of neonatal respiratory distress
Oesophageal atresia and tracheo-oesophageal fistula
Congenital diaphragmatic hernia
Congenital cystic adenomatoid malformation of the lung
Pulmonary sequestration
Enteric duplication cysts
Diaphragmatic eventration
Bronchogenic cyst
Congenital lobar emphysema
imaging post chest radiograph confirming oesophageal atresia
normally just an echo for sid eof aortic arch and cardiac anomalies ahead of surgery
mediastinal mass which is displacing the trachea to the left
differentials
bronchogenic cyst
cystic hygroma
enlarged lymph nodes
We must define where in the chest the abnormality exists. The fact that the lesion extends below the diaphragm means it must be XXXX
on chest XR
posteriorly situated
if the chest drain is too medial it can damage what structure
phrenic nerve
how to determine laterality of pathology on a unilateral hypodense lung
inspiratory vs expiratory film: no change is abnormal
dense normal vessels: normal
low vessels: abnormal
Causes of a large hyperlucent hemithorax
Compensatory emphysema
Obstructive emphysema
Pneumothorax
categories of obstructive emphysema
INtraluminal - mucus, foreign body
intramural - haemangioma, bronchomalaica
extraluminal - bronchogenic cyst, lymph
hyperlucent hemithorax
primary abnormality of pulmonary blood flow
Pulmonary arterial hypoplasia
Unilateral pulmonary stenosis
Cardiac shunt procedure with unequal pulmonary blood flow
Pulmonary embolism (rare in children)
The presence of the small lung, decreased pulmonary vascularity and evidence of bronchiolitis obliterans is often referred to as
McCleod’s or the Swyer-James syndrome.
A hyperlucent small lung
In association with a previous history of pneumonia
It is not unusual to demonstrate abnormalities in the ‘normal’ lung on ventilation/perfusion imaging and CT scanning
Increased translucency of both hemithoraces is commonly associated with hyperinflation of the lungs and may be related to
Exuberant inspiration
Hyperinflated lungs, which may be obstructive or non-obstructive
Decreased pulmonary blood flow (may be normal lung expansion)
Free intrathoracic air
Non-obstructive hyperinflation
This is also referred to as physiological hyperinflation.
causes
acidosis and congential heart disease
mechanical ventilation
dehydration (through oligaemia)
obstructive hyperinflation
Peripheral airway obstruction, such as
Meconium aspiration
Bronchiolitis
Asthma
Bronchopulmonary dysplasia
Cystic fibrosis (CF)
Immunologic deficiency
obstructive hyperinflation
central airway obstruction
Tracheal foreign body
Tracheal compression
Tracheobronchomalacia
Peribronchial cuffing is best seen in the
right middle lobe.
Peribronchial cuffing is best seen in the
right middle lobe.
oligaemia and boot shaped heart think
Tetrology of fallot
Anterior tracheal and posterior oesophageal impressions, with bilateral lateral oesophageal impressions
Innominate artery with left aortic arch
what vascular anomaly is this?
double aortic arch
Post oblique oesophageal impression and normal trachea
RSA with left aortic arch
Post tracheal impression and anterior oesophageal impression
pulmonary artery sling
Anterior tracheal impression and normal oesophagus
innominate artery with left aortic arch
Anterior tracheal and posterior oblique oesophageal impressions
right aortic arch with lsa
anatomy relations of the pulmonary artery bronchus and vein at the hilum on left and right
Note that the left pulmonary artery crosses over the left main bronchus becoming posterior to the left main bronchus. This is unlike the right pulmonary artery which passes anterior to the right main bronchus.
Categories of enlarged lymph nodes
Infection: lower respiratory tract infection, mycoplasma, tuberculosis (TB), fungal
Neoplasm: lymphoma/leukaemia and secondary neoplasms such as osteosarcoma, Ewing’s, metastasis
Cystic fibrosis
Histiocytosis
Sarcoidosis
Cold agglutinins are positive on blood testing
think mycoplasma
unilateral hilar adenopathy +/- paratracheal adenopathy.
TB`
pulmonary valve stenosis causes unilateral or bilateral hilar enlargement
bilateral
what is cystic fibrosis - gene and how it transpires
Auto Recessive
mutation of fibrosis transmembrane conductance regulator gene
1 in 2500
cystic fibrosis - associated abnormalities
Pancreatic insufficiency
Gastrointestinal and hepatobiliary disease
Nasal polyps
Sinusitis
Infertility
Cystic fibrosis - pathogens for pneumonia
Staph aureus and pseudomonas
most common presentation of gastro-intestinal disease in cystic fibrosis is with bowel obstruction in the newborn due to XXXX
meconium ileus
others
volvulus
fibrosing colonopathy
intussusception
Peptic ulcer
colitis
rectal prolapse
complications of meconium ileus
occurs in 50% of infants
meconium peritonitis
ileal atresia
perforation
volvulus
CT scan shows the liver has a lower attenuation than the spleen consistent with….
fatty liver
if a patient has meconium ileus, 90% will have
Cystic fibrosis
prtoprtion of paeds tumours are neuro?
15%
second commonest tumour
supra vs infra tumours based on age
supra more comon in under 3
infra more common 4 to 10 and over 10 the same
Raised ICP is a sign of aggreessive or insiduous brain tumours?
aggressive
symptoms of cranial sutures unfused
Increasing head circumference
Nausea/vomiting
Irritability
If sutures are fused brain malingnant features are
Headaches
Visual disturbances
Seizures and focal neurological signs and symptoms, such as ataxia and cranial nerve (CN) palsies
cOMMONEST CHILDHOOD BRAIN TUMOURS
atrocytic tumours (50%)
then
primitive neurectoderman tumours
- infratentorial medulloblastoma
- supratentorail PNET
Commonest adult brain tumours
high grade astrocytic tumours such as anaplastic astrocytoma
Glioblastoma multiforme
Neonatal tumours are…
teratoma,
hypothalamic astrocytoma
choroid plexus papilloma and PNET.
brain cancer - MRI sequence and protocol
bolus of paramagnetic contrast and should include post-contrast T1W images.
Coronal FLAIR
DWI and ADS
axial T1 T2
SPine
sag T1 (post gad)
ax T1
Which imaging modality is the modality of choice when there is high suspicion of an intracranial tumour in a child and why?
MRI
propensity to spread via the CSF -tumours will appear as
resulting in either multiple (usually) enhancing lesions in the subarachnoid space and/or diffuse smooth or nodular enhancement of the pia mater over the brain
tumours have the propensity to spread via the CSF
Primitive neuroectodermal tumour e.g. medulloblastoma, supratentorial PNET, Pineoblastoma/pineocytoma
Supra and infratentorial ependymoma
Germ cell tumours
High grade astrocytic tumours e.g. anaplastic astrocytoma, glioblastoma multiforme (GBM)
Choroid plexus tumours e.g. papilloma and carcinoma
common cerebellar tumours
Medulloblastoma
Astrocytoma - low grade (e.g. pilocytic astrocytoma) and high grade (e.g. anaplastic astrocytoma)
Ependymoma
common brainstem tumours
Pontine glioma
Tectal plate glioma
most common infratentorial paediatric brain tumour
medulloblastoma
why does medulloblstoma have
solid CT apperaance
and cuase hydrocephalus
invasdes vermis and 4th ventricle.
made up of tightly compact round cells
grades of astrocytoma
1 to 4
1 juvenil pilocytic astrocytoma
4 - anaplastic astrocytoma
ASTROCYTOMA FOUND WHERE
MIDLINE STRUCTURE
ASSOCIATIONS astrocytoma
NF1
what are the three appearances of an astrocytoma?
Cyst with mural enhancing nodule: 50% (Fig 1)
Rim-enhancing mass with necrotic/cystic centre: 40-45% (Fig 2)
Non-necrotic solid mass
astrocytoma enhance
YES
what density is astrocytomas
can be low density most of th etime.
high grade can be isodense to grey matter though - increased cellularity
what is the fluid in cystic astrocytomas like
slight denser than csf
who gets affected by ependymoma?
kids 1 to 5
slightly more boys
what disease is true (rare) and pseudo- (more common) perivascular rosettes,
Ependymomas
why does ependymoma present with lower cranial nerve palsies ?
extension through the
Lushka and Magendie formaina
appearance of infratnetorial ependymoma
clacification and small cysts
invades 4th ventricle and expands it
invades lushka and magendie
out through foramen magnum
enhances around necrotic areas
Ependyomoma MRI features
predominantly iso to hypointense to GM on T1W
especially heterogeneous on T2W imaging
iso to hyperintense solid components, hyperintense intratumoural small cysts and hypointense areas due to calcification or blood products
Mild to moderate heterogeneous enhancement
How to differentiate a medulloblastoma and ependymoma infratentorial lesion
Does it invade lusdka / magendie
features of glioma to wathc out for
surround the bsailar artery
can compress the 4th ventricle
invades the pons, infiltartes
Tectal plate gliomas are assocaited with
NF1
Subependymal giant cell astroxytosis is only found in which disease
Tuberous sclerosis
differentiate suependyaml astrocytoma and hamartoma that look similar
the subependymal astrocytoma will grow
pyloric stenosis presents when
6 weeks
where to find the pylorus on US
behind the gallbladder
pylorus measurements taken in which plane
longitudinal
Laryngitis causes can be divided by
Location of obstruction
Supraglottic
Laryngomalacia
Epiglottitis
Foreign body
Trauma
Glottic
Laryngeal web
vocal cord palsy
recurrent respiratory papillomata
foreign body
trauma
Subglottic
Laryngo tracheo bronchitis
subglottic stenosis
tracheomalacia
haemangioma
abnormal vessels
complete tracheal ring
foreign body
truama
acute epiglottitis is uncommon now due to
HiB vaccine
tracheobroncholmalacia - hwat happens to the aireway in expiration
it collapses
Risk factors for tracheobronchomalacia include
prematurity,
tracheo-oesophageal fistula,
vascular ring and congenital heart disease
The laryngeal web is usually located
between the cords anteriorly.
chest xr - posterior junctional line suggests what?
hyperinflated lungs present
mbryologically thymus is derived from
the third pharyngeal pouch
At what age won’t you see the thymus on a chest xr
6 plsus
often after 3 though
thymus size will change acutely with
illness
reduces with endogenous steroids. Cna then get rebound much bigger
22q11 deletion syndromes eg
DiGeorge/congenital thymic aplasia, velo-cardio-facial syndrome (VCFS) or Shprintzen syndrome
22q11 deletion syndromes caused by what
failure of normal development of the third and fourth branchial arches
Absence of the thymus and parathyroids, congenital heart disease, oesophageal atresia and facial abnormalities
5 normal features of cxr thymus
Widened superior mediastinum
Notch at the junction with the heart
Smooth, well-defined, convex lateral border
Scalloped/wavy left lateral border cause by indentation by the anterior rib ends
No mass effect or adjacent structure,
which embryological layer gives rise to the kidneys
dorsal mesoderm
What are the common kidney congenital abnormalities?
Autosomal recessive polycystic kidney disease (PCKD)
Autosomal dominant PCKD
Multicystic dysplastic kidneys (MCDK)
Potter syndrome
Duplication of the urinary collecting system
Nephroblastomatosis: persistence of undifferentiated metanephric blastema cells
Wilms’ associations
Ureterocoele
What is the anatomical differnece between recessive and dominant polycystic kidney disease?
Recessive - collecting ducts
how does wilms tumour come about?
nephric blastema remains undifferentiated
syndromic associations of WIlms
Beckwith-Wiedemann syndrome and hemihypertrophy.
nship of nephtogenic rests, Nephroblastomatosis and wilms
normal cells that involute.
nephroblastomatosis is benign involvement.
Wilms is malignant
multiple arteries to a kidney due to
failure of resorptoin of vessles as the kidneys move higher up the abdomen
what is crossed fused ectopia for a kidney
This variant results when one kidney crosses over and fuses with the contralateral kidney, and both ascend together to form a unilateral kidney.
what classic feature distinguishes Wilms tumour from neuroblastoma?
Vascular invasion
Under 6 months - freqwuency of uti to need an US scan
just the one
filler bladder - normal wall thickness
up to 3mm
what pathology is looked for on US bladder
Thickening of the bladder wall
Ureterocoele
Dilated distal ureter(s)
Pelvic masses
Antenatal hydronephrosis
calyceal dilattion
parenchymal thinning
cortico-medullary differentitation
increased parenchymal echogenicity
renal cysts
ureteric dilatation
oligohydraminos
Antenatal hydronephrosis - what are the markers of poor prognosis ?
renal dysplasia and oligohydramnios
imaging options for suspected renal obstruction in postnatal baby
MAG3
MRI
IV U
If vesicoureteric reflux is susspeced
direct imaging - fluro, radionuclide, cystosonography
indirect - voiding mag3
what should be done ig posterior urethral valves are suspected?
catheter
prophylactic abx
voiding cystourethrogram
what is the Weigert-Meyer rule
up obstruct, low flow(reflux)
There is obstruction of the upper renal moiety and ureter by an ectopic ureterocele situated at an abnormal ureteric insertion, as illustrated: the dilated upper moiety pelvicalyceal system is associated with a tortuous, dilated ureter and an obstructing ureterocele
The lower moiety vesicoureteric junction is normally sited, superior and lateral to the upper moiety ureteric opening, but is prone to VUR
how to differentiatie hydronephrosis from MCDK
MCDK has lots of cysts so the areas aren’t connected
The most frequent cause for a solitary normal kidney which exhibits compensatory hypertrophy is ?
complete involution of a contralateral MCDK.
commonest cause of haematuria in children
UTI
Calculi
Trauma
Glomerular causes of haematuria: charachterised by what features
abnromal red cell morphology (distorted as traverse the basement membrane)
Proteinuria
red cell and tubular casts in urine
non-urological cause if most frequent
OFTEN MICROhaematuis
non-Glomerular causes of haematuria: charachterised by what features
presence of intact red cells in the urine
urological cause is most frequent
macrohaematuria most common
Cuases of microhaematuria
Glomerulonephritis (various types)
Familial nephritis (Alport’s disease)
IgA nephropathy
Poststreptococcal
Henoch-Schönlein purpura
causes of macrohaematuria
Urinary tract infection
Trauma (including iatrogenic)
Calculi
Tumours
Vascular lesions, for example renal venous or arterial thrombosis and arteriovenous connection
What is Henoch Schonlein purpura
acute vasculitis affecting small vessels in children. It is caused by a systemic allergic response, which may be caused by conditions such as infections, insect stings and drug reactions.
UTI accounts for what proportion of macro haematuria in kids
25%
7 types of calculi
rate, struvite, cystine, calcium oxalate, calcium phosphate, matrix (mucoprotein) and xanthene
can tumours cause haematuria?
yes, but very rare. Wilms tumour. Rhabdomyosarcoma normally obstuction.
angiomyoliopomas, possible
Renal vein thrombosis
risk factors in neonates
dehydrated and hypotension
US fetures of renal vein thrombosis
Enlargement of one or both kidneys
Reduced echogenicity in the kidney owing to oedema, but echogenic intrarenal haemorrhage may be seen
Reduced/absent flow in the renal vein with or without thrombus
Diminished/reversed diastolic flow in the renal artery
recommended scheme of investigation of an atypical UTI in a child aged <6 months is
Sonography
A DMSA scan (after 4-6 months for scarring)
An MCUG
DMSA binds to what?
proximal tubular cells
coloiform bacteria is typcial or atypcial for uti
atypical
how is hypertension meausured in kids
x3 occasions where bp is greater than 95% percentile for age
what is the main cause of hypertension in paeds
renal pathology - RAS, renovascular malformations.
neonate - occlusion from catheter
over 12 think drugs or renal parenchymal disease
in US kidneys for hypertension what needs to be examined?
Renal size
The presence of parenchymal scarring`
The presence of collecting system dilatation
The presence of adrenal masses
Examination of the aorta
In Renal US - if the RI is 0.5 (normal is 0.7) what are the thoughts on diagnosis.
more of a parvus et tardus waveform.
Upstream dilatation (could be in aorta) - no pulsitile waveform
what is the difference between dimercaptosuccinic acid and mercaptoacetyltriglycine for renal studies.
DMSA stays in proximal convoluted tubules - can show defects like scarring.
Mercaptoacetyltriglycine - for dynamic studies of tubular secretion. Perfusion, transit and drainage
most common renovascular disorder encountered in children is
fibromuscular dysplasia
differnetials for FMD
Williams
NF1
what takes up MIBG?
Neurblastoma
Haeo
Normal adrenal medulla
Ganglionneuroma
why are first and second ribs spared in coarctation rib notching
supplkied by the sublcavians
Renal cysts can be classified into which two groups?
Genetic disease and non genetic disease
genetic causes of cystic kidneys
Autosomal recessive polycystic kidney disease (ARPKD)
Autosomal dominant polycystic kidney disease (ADPKD)
Tuberous sclerosis
Juvenile nephrophthisis
Glomerulocystic kidney disease
Cysts with multiple malformation syndromes
non genetic causes of cystic kidney
simple
dysplastic kidney
Multilocular renal cysts
CKD
calyceal diverticulum
Medullary cystic kidney
medullary sponge kidney
which imaging is used for renal cysts
US
MRI
NucMed
extra renal cysts - look in which organs
pancreas, spleen and liveer
The most important feature of ARPKD is that
both kidneys are enlarged and this diagnosis should never be made if the kidneys are normal or small in size.
ARPKD - what happens to liver and biliary tree
hepatic fibrosis and cystic dilatation of the biliary tree
look for portal hypertension ect
bone lesions - over 40 differential diagnosis includes
infective
mets
myeloma
lymphoma
Types of matrix mineralisation
osseous
chondral ground glass
Ground glass bone matrix mineralisation is what
‘Ground-glass’ density due to numerous fine spicules of bone is seen within the lesion. Punctate calcium is also possible.
slow growing lesions are which
Cysts/geodes
Simple bone cysts (SBC)
Enchondroma
Resolving LCH
Brodie’s abscess
types of cortical response to a tumour
Expanded =
scaplloped - Chondral and fibrous
trabeculated - cysts/GCT
Types of periosteal reaction and their cancers
(solid/cortical thickening)
onion-skin
(spiculated)
Aneurysmal bone cyst (periosteal buttress)
Osteoid osteoma (solid/cortical thickening)
Ewing’s sarcoma (onion-skin)
Osteosarcoma (spiculated)
Aneurysmal bone cyst (periosteal buttress)
types of spiculated bone for bone lesion
Perpednciular - reactive bone - ewings, mets,
divergent - sunburst. osteosarcoma.
velvet - disorgansied, ewings
Typically, osteosarcoma will be found WHERE
metaphyseal in location, often found in the distal femur, proximal tibia or proximal humerus (Fig 3).
OSteosarcoma - what age
adolescents
Ewing s- age group
5 - 25
In ARPKD what should the parents have?
Normal kidenys as it is recessive
AD PKD manifests when?
third decade of life
half patients are spontaenous mutations, no fam histroy
what is the main dangerous assocation with AD PKD
subarachnoid haemorrhage
AD PKD needs to be differentiated form which condition ?
Tuberous sclerosis
What are some of the other manifestations of TSC that one might look for?
Rhabdomyelomas cardiac
Corticol tubers in brain
The renal abnormalities associated with TSC include:
Cysts
Angiomyolipomas
Angiomyolipomas and cysts
What is Multicystic dysplastic kidneys
non hereditory.
Failure of that kidney.
wide spectrum
non functioning on Nuc Med
sponatenous involution
Medullary sponge kidney is a rare diagnosis to make in children, and must be characterised by:
Haematuria
Nephrolithiasis
Infection
NOT enlarged
investigation algorithm for unliateral cysts
MCDK - MAG3
Simple cysts - IVU
Multilocular cystic nephroma- cross section
investigat algorithm for bilateral cysts
Genetic - TSC, ARPKD, ADPKD
Dysplasia - MCU / MAg3
VACTERL stands for
vertebral defects, anal atresia, cardiac defects, tracheo-esophageal fistula, renal anomalies, and limb abnormalities
Autosomal recessive polycystic kidney disease. This condition describes
very large kidneys with small cysts, which result in a large bright kidney appearance
Autosomal dominant polycystic kidney disease is a common condition that starts in childhood. The kidneys vary from
normal to enlarged, and there are a variable number of large cysts on each kidney. Renal involvement is often not bilaterally symmetrical
In TSC, the kidneys may contain
angiomyolipomas and/or large cysts. There may be a family history of TSC, or the condition might have arisen as a new mutation
how bright is the kidney in neonates to 6 months
should be brighter than the liver
The reasons for this difference are the relatively large volume of glomeruli versus medullary pyramids and the lack of echogenic sinus fat in the neonate.
Pre renal causes of AKI
hypovolaemia
hypotension
hypoxia
Renal causes of aki
Glomerulonephritis
Intravascular coagulation
ATN
AIN
Tumours
Developmental
Hereditary nephritis
Post renal causes of AK I
Obstructive uropathy
Vesicoureteral reflux
Acquired - stones
The renal medullae appear hypoechoic and prominent on normal ultrasonographic examination of the neonate
why?
lack of echogenic sinus fat
How to commnet on kidneys in US
size, morphology, echotexture, pelvicalyceal dilatation and perfusion
what is the cut off of difference between kidneys that raises suspicion?
over 10% concern for scarring
demonstrating pelvicalyceal dilatation. The possibility of false positives should be borne in mind; for example,
extrarenal pelvis,
large major calyx,
recent obstruction or infection, clubbed calyces,
secondary to reflux or papillary necrosis.
Renal venous thrombosis leads to diminished venous signals and produces characteristic changes in the waveforms of the main renal artery and its branches with….
sharp systolic peaks and reversed diastolic flow.
What are the differentials for
echogenic kidneys with loss of corticomedullary differentiation
Unwell baby
- Asymmetrical, renal vein thrombosis
- symmetrical, ATN
Well baby
- Enalarged, ARPCKD
- Small, dysplastic kidneys
What are the main causes of CKD in kids under 5
anatomical abnormalities
- hypoplasia, dysplasia, obstruciton, malformation
What are the main causes of CKD in kids over 5
Acquired glomerular disease and herediatary
- HUS
- Alport
- Cystic disease
- Glomerulonephritis
Lentiform nucleus + caudate nucleus =
basal ganglia
Putamen + globus pallidus =
lentiform nucleus
Putamen + head of caudate nucleus =
corpus striatum
what is Periventricular Nodular Heterotopia
neurons develop in the germinal matrix and do not migrate
bumbpy inner ventricle lining
what is focal heterotopia?
Groups of neurons may start to migrate but not reach the surface.
These can be recognised as a clump of tissue of grey matter intensity lying within the brain substance.
what is classical lissencephaly
disorder of neuronal migration in which the cortex is abnormally organised and thicker than usua
Types of classical lissenencephaly
agyira
pachy gyria
SBG
how to differentiate between polymicrogyria and pachygyria
polymicrogyria are small so interdigitate with the wqhite matter - so no boundary is seen
abnormal grey matter is what on T2W
high signal
Grey matter - corpus striatum (head of caudate and putamen) are affected
what are the differentials ?
Mitochondrial disorders
Leighs, MELAS, hypoglycaemia
Grey matter - mainly globus pallidus is affected with high signal T2
what are the differentials?
Methylmalonic acidaemia
L-2 hydroxyglutaric acidaemia
CO poisoning
Kernicterus
NG1
Grey matter - mainly globus pallidus is affected with high signal T2
what are the differentials?
Methylmalonic acidaemia
L-2 hydroxyglutaric acidaemia
CO poisoning
Kernicterus
NF1
Grey matter
Mainly thlamic involvement
what differentials
Krabbes disease
Gangliosidoses
Wilsons
Bilateral proptosis in early infancy is often due to a
developmental bone abnormality.
Unilateral proptosis is usually due to
an orbital mass.
Rapidly progressive proptosis suggests an aggressive neoplasm such as
rhabdomyosarcoma
main causes of proptosis in children?
Haemangioma
Venous lymphatic malformation
Dermoid cyst
Sinusitis and orbital cellulitis
Optic nerve glioma
Rhabdomyosarcoma
Neuroblastoma
Langerhans’ cell histiocytosis
Bone dysplasias (e.g. fibrous dysplasia, osteopetrosis, craniofacial abnormalities)
Causes of periosteal reaction in children ?
Physiological
Trauma
Infection
Tumour
Metabolic
Chronic disease
Inherited conditions
Caffey disease
Iatrogenic
sickle cell osteomyelitis is what organism?
Sallmonella
chronic relapsing mutifocal ostemyelitis typcially involves what bones?
medial clavicle
Physiological peri osteal reaction is allowed to be how deep
2mm
Leukaemia and metastatic neuroblastoma may both give rise to periosteal reactions with…. what
lucent metaphyseal bands
