RD paediatric formatted Flashcards
- Neck mass in 3 month infant. High flow, high velocity, low resistance. Which is most likely
a. Infantile hemangioma
b. Macrocystic lymphatic malformation
c. Arteriovenous malformation
d. Microcystic lymphatic malformation
e. Venolymphatic malformation
.f. Congenital haemangioma
g. Venous malformation
*AJL - This may be either infantile or congenital haemoangioma. There is not enough information to determine which it is. (congenital = present at birth, infantile = not present at birth)
Previous answers:
a. Infantile hemangioma T – see below.
JMIRO 2012 (Mitesh): “Soft tissue mass that is predominantly hypoechoic with high-velocity colour flow, high vessel density and low resistance”. US Clin 2009: the presence of a distinct mass at sonography, the high vessel density, and the low RI with Doppler are the most important diagnostic criteria of infantile hemangioma. Mean peak arterial flow velocity 28 cm/s. Most common tumour of head & neck in infancy (RadClin 2011).1.
Neck mass in 3 month infant. Growing. High flow, high velocity, low resistance. Which is most likely (Radiographics May-June 2009 p887; JMIRO 2012)
a. Infantile hemangioma T – see below. JMIRO 2012 (Mitesh): “Soft tissue mass that is predominantly hypoechoic with high-velocity colour flow, high vessel density and low resistance”. US Clin 2009: the presence of a distinct mass at sonography, the high vessel density, and the low RI with Doppler are the most important diagnostic criteria of infantile hemangioma. Mean peak arterial flow velocity 28 cm/s. Most common tumour of head & neck in infancy (RadClin 2011).
b. Macrocystic lymphatic malformation F – low-flow, large cystic spaces at US, grow with child
c. Arteriovenous malformation ? F – enlarge with size of child (present at birth, but usually manifest in childhood or later); high-flow vessels; but usually no definable mass (JMIRO 2012); US Clin 2009: characterized by multiple feeding arteries with increased diastolic flow and high-velocity venous return. Typically high-flow, low resistance. Arterial waveforms in venous structures.
d. Microcystic lymphatic malformation F – low-flow; composed of very small cystic components a few mm in size
e. Venolymphatic malformation. F – low-flow
f. Congenital haemangioma – F? - either involute in infancy (‘rapidly involuting congenital haemangioma’) or grow proportional with child (‘non-involuting haemangioma’); MR appearance similar to infantile haemangioma, although may have ill-defined margins
g. Venous malformation – F - low-flow, do enhance post GdANS = infantile haemangiomao Undergo a characteristic two-stage process of growth & regression:• At birth, typically small & inconspicuous (60% are not visualised at birth)• Shortly after birth, proliferative phase occurs – rapid endothelial growth in 1st few months of life, stabilising in size at ≈ 9-10 months of age• Following this the involuting phase continues slowly for the next several years, being replaced by fibrofatty tissue, and usually complete at 7-10 years of ageo US:• Discrete lobulated mass• Prominent colour Doppler high flowo MRI:• Proliferative phase:➢ Lobulated, well-defined mass➢ Hyperintense on T2W images & isointense to muscle on T1W images➢ Prominent draining veins seen as both central & peripheral flow voids on SE
- 10cm pancreatic cyst (cystic mass) in a young patient (25 years). (Incidental with no calcifications). Most likely is
a. Serous
b. Mucinous
c. Solid pseudopapillary
d. Insulinoma
e. Gastrinoma
c. Solid pseudopapillary T Young age suggests solid pseudopapillary neoplasm with predominate cystic degeneration. RG 2011 – F»M (9:1), young adult (mean age 25); typically large (mean 9cm); 30% have calcifications. Against this is no mention of solid components or haemorrhage.
- 10cm pancreatic cyst (cystic mass) in a young patient (25 years). (Incidental with no calcifications). Most likely is
a. Serous F mean age 65 years
b. Mucinous
c. Solid pseudopapillary T Young age suggests solid pseudopapillary neoplasm with predominate cystic degeneration. RG 2011 – F»M (9:1), young adult (mean age 25); typically large (mean 9cm); 30% have calcifications. Against this is no mention of solid components or haemorrhage.
d. Insulinoma F 4th-6th decades; usually small & hypervascular solid
e. Gastrinoma F 4th-5th decades; usually small & hypervascular solid
- Most likely location of a pulmonary sequestration
a. Right upper lobe
b. Right middle lobe
c. Left upper lobe
d. Right lower lobe
e. Left lower lobe
Left lower lobe•
BPS location: posterobasal segment of LLL is most common siteo LLL > RLLo Posterobasal > mediobasal segment
- NAI injuries. Which is most true?
a. Bucket handle (corner) metaphyseal fractures associated with twisting injury.
b. Long bone diaphyseal injuries are spiral (also recalled as: “Spiral fractures are most often seen in NAI”)
c. Posterior rib fractures more common than lateral
d. Posterior rib fractures less common (frequent) than anterior fractures
e. Bone scan for confirmation of the fracture age is better compared to x-ray
c. Posterior rib fractures more common than lateral T posterior rib fractures most common & most specific for abuse (Donnelly, StatDx)
- NAI injuries. Which is most true? (SK)
a. Bucket handle (corner) metaphyseal fractures associated with twisting injury F shearing injury, usually generated by manual to-and-fro manipulation of extremities (e.g. holding & shaking child)
b. Long bone diaphyseal injuries are spiral T they can be – can also be oblique or transverse. Quite specific for NAI if spiral fracture of long bone occurs in non-ambulatory (< 1 yr) child.Also recalled as: “Spiral fractures are most often seen in NAI” ?? F once a child is walking, spiral fractures of the tibia (Toddler fractures) are quite common, and often have no memorable traumatic antecedent, and by themselves are not suggestive of NAI.
c. Posterior rib fractures more common than lateral T posterior rib fractures most common & most specific for abuse (Donnelly, StatDx)
d. Posterior rib fractures less common than anterior fractures F = adult squeezes infant thorax; causes posterior rib fracture near costovertebral joint, but can also cause anterior & lateral rib fractures
e. Bone scan for confirmation of the fracture age is better compared to x-ray F “Bone scans have no place in fracture dating because they show positive results within 7 hr of injury and can continue to show positive results for as long as 1 year.” AJR April 2005.
- Features of pilocytic astrocytoma (which is false?)
a. The most common posterior fossa tumour
b. Calcify more commonly than medulloblastoma
c. Usually a less aggressive lesion
d. Usually more cystic than solid
e. Show enhancement after contrast administration
b. Calcify more commonly than medulloblastoma F JPA < 10% calcify, while 10-20% of MB’s calcify (NeuroReq); Osborn says up to 20% of MB calcify, while says “uncommon” in JPA; c.f. ependymoma 40-50% calcified at CT (most common PF tumour to calcify) SG reckons about the same
*LW - agrees this is FALSE and therefore correct answer, according to Donnely.
- Features of pilocytic astrocytoma (SK)
a. The most common posterior fossa tumour T in children (although some may MB is); peak age 8-13 years SG MB slightly more common
*LW: Donnelly states Pilocytic astrocytoma most common posterior fossa tumour, thus taken as TRUE.
b. Calcify more commonly than medulloblastoma F JPA < 10% calcify, while 10-20% of MB’s calcify (NeuroReq); Osborn says up to 20% of MB calcify, while says “uncommon” in JPA; c.f. ependymoma 40-50% calcified at CT (most common PF tumour to calcify) SG reckons about the same
*LW as above, FALSE.
c. Usually a less aggressive lesion T WHO grade I tumour:
d. Usually more cystic than solid T typically well-circumscribed cyst-like masses with a discrete mural nodule – one-third are microcystic or solid, esp. in older patients
e. Show enhancement after contrast administration T solid portion (cyst with enhancing mural nodule)
- 11 yo girl with 4th ventricle tumor. Most likely (repeat)
a. Choroid plexus papilloma
b. Oligodendroglioma
c. Ependymoma
d. Haemangioblastoma
e. Medulloblastoma
e. Medulloblastoma T arise from roof of 4th ventricle; older age than ependymoma but usually < 10 years; 2nd most common PF tumour in kids (after JPA) Doesn’t
- Cortically based tumour:
a. Low grade glioma
b. DNET
c. Pilocytic astrocytoma
d. Cavernous haemangioma
e. Ependymoma
b. DNET - T - benign, focal intracortical mass superimposed on background of cortical dysplasia. Arises from secondary germinal layer of CNS, in particular the subpial granular layer.
- Cortically based tumour:
a. Low grade glioma – F typically involve WM. However the pleomorphic xanthoastrocytoma (PXA) is cortically-based.
b. DNET - T - benign, focal intracortical mass superimposed on background of cortical dysplasia. Arises from secondary germinal layer of CNS, in particular the subpial granular layer.
c. Pilocytic astrocytoma - F - arises from astrocytic precursor cell. Typically cerebellar mass (hemisphere) which compresses 4th ventricle
d. Cavernous haemangioma - F
e. Ependymoma - F - floor of 4th ventricle mass, slow-growing tumour of ependymal cells.
Kid in accident. Has lesion that is consistent with angiomyelipoma. Clinical stable.
Next best step.
- MRI
b. DSA
c. family hx
d. renal scintigraphy
e. urgent surgery
ANS• If patient bleeding into AML / retroperitoneum, DSA (B) and transarterial embolisation indicated•
If not bleeding, may have conservative management (e.g. US follow-up) or elective surgical/IR management
Wunderlich syndrome = haemorrhagic shock due to massive bleeding into AML or retroperitoneum (Dahnert).J Trauma. 2005;59:737–741:
SUFE.
a. rarely dx on AP
b. usually 5-10 years of age
c. usually bilateral
d. usually posteromedial slippage
e. in early slippage frog leg view is best
D = T = epiphysis rotated posteriorly & inferomedially
*LW: agrees TRUE.
E ? trueEmedicine: “The lateral radiograph demonstrates slippage earliest because the slippage begins with posterior displacement and progresses with medial rotation.” “Before the femoral epiphysis actually has become displaced, only a slight widening of the affected physis may be evident.”
*LW: agrees also TRUE.
*AJL - agree that both D and E are true (as above)
- Regarding myelination of the brain:
a. As myelination progresses the white matter becomes T1 hypointense.
b. The posterior internal capsule is myelinated at birth.
c. The optic nerves are myelinated by 2 months of age.
d. The splenium of the corpus callosum myelinates first, myelination then progresses anteriorly.
e. At 24-30/12 the white matter is isointense to grey matter on T2.
I guess this question is asking which one is most true
d. The splenium of the corpus callosum myelinates first, myelination then progresses anteriorly. T dorsal to ventral, caudad to cephalad, central to peripheral. Splenium bright on T1 at 4 mths, genu at 6 mths; then low on T2 by 6 mths and 8 mths respectively. [Kieran’s ‘rules’]
- Regarding myelination of the brain:
a. As myelination progresses the white matter becomes T1 hypointense. F with myelination, deceased amounts of water → T1 hyperintense & T2 hypointense
b. The posterior internal capsule is myelinated at birth. T the posterior portion of the posterior limb of IC is myelinated at birth on T1 (2 mo on T2), anterior part by 1mo (4-7 mo on T2); anterior limb at 2-3mo (5-11 mo on T2)
c. The optic nerves are myelinated by 2 months of age. T optic nerves & tracts myelinated by 1 mo
d. The splenium of the corpus callosum myelinates first, myelination then progresses anteriorly. T dorsal to ventral, caudad to cephalad, central to peripheral. Splenium bright on T1 at 4 mths, genu at 6 mths; then low on T2 by 6 mths and 8 mths respectively. [Kieran’s ‘rules’]
e. At 24-30/12 the white matter is isointense to grey matter on T2. F
- A 3 year old child has a 1.5cm lesion at the dorsal aspect of the nose. It is bright on T1 and T2 weighted MR, and demonstrates a fibrous band which extends to a pit in the foramen caecum of the frontal bone. It MOST LIKELY represents:
a. Dacrocystocoele
b. Glioma
c. Encephalocoele
d. Choanal atresia
e. Nasal dermal sinus
*AJL - I wonder if this was meant to say nasal dermoid sinus which is bright on both T1 and T2 (contains sebum/fat). Please change the question/answer if you agree.
e. Nasal dermal sinus
B = nasal glioma (F) = T1 mixed-low, T2 hyper-, pedicle of fibrous tissue b/w ING & intracranial cavity
C = encephalocele (F) = connection to intracranial brain parenchyma
E = nasal dermal sinus (?T) = T1 hyper-, T2 intermediate; may have associated sinus tubular tract from tip of nose to apex of crista galli
- Regarding bronchogenic cysts, which is the LEAST correct?
a. Communicate with the bronchial tree
b. Occur in the mediastinum more than the lung
c. Are part of a spectrum of foregut cysts
d. When have a thick contrast enhancing wall indicate infection
e. High T2 signal
a. Communicate with the bronchial tree F – Do not communicate with bronchial tree unless/until they become infected
- Regarding bronchogenic cysts, which is the LEAST correct?
a. Communicate with the bronchial tree F – Do not communicate with bronchial tree unless/until they become infected
b. Occur in the mediastinum more than the lung T – 65-90% occur in middle mediastinum
c. Are part of a spectrum of foregut cysts T aka foregut duplication cyst
d. When have a thick contrast enhancing wall indicate infection T
e. High T2 signal T - Signal is almost always equal to or greater than cerebrospinal fluid (CSF)
- 3 month child with a neck mass which has been present since birth and has grown with the child. Ultrasound shows a compressible lesion with low monophasic flow. Which is MOST likely?
a. Venous malformation
b. Lymphatic malformation
c. Arterial malformation (also recalled as AVM)
d. Infantile haemangioma
e. Cavernous haemangioma
a. Venous malformation T frequently evident at birth & grow proportional to child
- 3 month child with a neck mass which has been present since birth and has grown with the child. Ultrasound shows a compressible lesion with low monophasic flow. Which is MOST likely?
a. Venous malformation T frequently evident at birth & grow proportional to child
b. Lymphatic malformation F no flow in cysts, only in septae
c. Arterial malformation (also recalled as AVM) F would have high flow, pulsatile; do not present as masses
d. Infantile haemangioma – F small & inconspicuous at birth, rapid growth in 1st few months of life, stabilising in size at 9-10 months of age. They then involute slowly, complete by 7-10 years.
e. Cavernous haemangioma – T/F misnomer for venous malformation; frequently evident at birth & grow proportional to child
- 11 yr old female with ataxia and headache has a posterior fossa mass which is hyperdense and enhancing, it is likely to be…
f. Medulloblastoma/PNET
g. Meningioma
h. Pilocytic astrocytoma
i. Ependymoma
a. Medulloblastoma/PNET – typically < 10 yrs, M>F, iso-hyperdense, heterogenous enhancement
- 11 yr old female with ataxia and headache has a posterior fossa mass which is hyperdense and enhancing, it is likely to be..
a. Medulloblastoma/PNET – typically < 10 yrs, M>F, iso-hyperdense, heterogenous enhancement
b. Meningioma – rare in children unless NF-2
c. Pilocytic astrocytoma – 8-13 years (right age), cyst with mural nodule
d. Ependymoma – peak age 1-5 years, hypo-isodense, calcification 40-50%, plastic
Drowsy kid with meningism. Best diagnostic test.
a. CSF
b. CTB non contrast
c. CTB post contrast.
d. MRI brain
B. - if very drowsy
A - if not too drowsy
French guidelines: CNS imaging is indicated if:
• Focal neurology
• GCS ≤ 11
• Seizures if > 5, only if hemiseizure in kids < 5
RCH guidelines on LP & CT:
CT Scans if focal neurological signs
• CT Scans are not helpful in most children with meningitis.
• A normal CT scan does not tell you that the patient does not have raised ICP.
• Herniation may occur even in the presence of a normal scan.
• Don’t delay antibiotics whilst waiting for a CT UK
NICE guidelines:Use clinical assessment and not cranial computed tomography (CT), to decide whether it is safe to perform a lumbar puncture.
CT is unreliable for identifying raised intracranial pressure. In children and young people with a reduced or fluctuating level of consciousness (Glasgow Coma Scale score less than 9 or a drop of 3 or more) or with focal neurological signs, perform a CT scan to detect alternative intracranial pathology.
Least supportive of EG in a kid with back pain and loss of vertebral body height at T7
a. mass
b. involvement of posterior elements.
c. wedge shaped compression
*LW:
Favoured answer is involvement of posterior elements:
Radiographic states: EG can initially cause wedge like or uneven lateral compression of vertebral bodies, before developing complete vertebra plana.
Often multifocal
Commonly small para spinal soft tissue mass.
Involvement of posterior elements uncommon / destruction of posterior elements is atypical - hence most unlikely.
Probably B
LCH in spine
- Disc-sparing vertebra plana (collapse of body to thin disc) or anterior wedging
- Destructive lytic lesion (esp. in upper C spine)
- Small paraspinal/epidural soft tissue component common
PedRad 2005 article … Spine LCH section“In the spine, LCH mainly involves the vertebral bodies, with a predilection for the thoracic spine followed by the lumbar and cervical spine. Posterior element involvement is less common. Involvement of the vertebral body may result in anterior wedging or, more commonly, near collapse with a characteristic vertebra plana appearance. Epidural soft-tissue extension may be seen on CT or MR imaging. Partial or almost complete height reconstitution is the usual healing pattern observed in vertebra plana lesions [22]. Neurological deficits usually resolve as osseous healing progresses.”
kid with widened ribs and enlarged vertebral bodies. Most likely
a. marrow hyperplasia
b. sickle
c. anapaestic anaemia
ANS = A = marrow hyperplasia → widening of medullary spaces
ADB–>Original option A) in the hard copy was thalassemia, which would get widened ribs and enlarged vertebral bodies (initially before end plate compression #’s occur)
not associated with renal anomalies
a. turners
b. hemihypertrophy
c. medulloblastoma
PNET-MB = no association foundDahnert
A = Turner = assoc/ w/ horseshoe kidney
B = hemihypertrophy = ? Beckwith-Wiedermann S = assoc/ w/ visceromegaly (incl. kidney), medullary dysplasia, Wilms tumour
C = PNET-MB = no association found
Hemihypertrophy of any aetiology is associated with Wilms tumour. BW is associated with embryo nail tumours in general including Wilms
1) Baby with small mass medial canthus, low T1, high T2. Most likely:
i) Glioma
ii) Nasal Dacrocystocele
iii) Choanal atresia
iv) Encephalocele
ii) Nasal Dacrocystocele T = T1 low, T2 high, minimal if any rim enhancement
2) Regarding holoprosencephaly, which is least correct:
i) Is associated with endocrine abnormalities
ii) Increase in incidence likely secondary to more awareness of mild forms
iii) Caused by mutations in Sonic Hedgehog gene
iv) Lobar form associated with non fusion of central grey matter
ii) Increase in incidence likely secondary to more awareness of mild forms ??F
2) Regarding holoprosencephaly, which is least correct:
i) Is associated with endocrine abnormalities (T - J Pediatr Endocrinol Metab. 2005 Oct;18(10):935-41) Diabetes insipidus (DI) occurred in 70% of patients with classic HPE. The severity of the DI correlated with the grade of HPE and hypothalamic non-separation (p < 0.0001). Anterior pituitary dysfunctions were much less common. Hypothyroidism was identified in 11% of patients, hypocorticism in 7%, and growth hormone deficiency in 5%.
ii) Increase in incidence likely secondary to more awareness of mild forms ??F
iii) Caused by mutations in Sonic Hedgehog gene (T – Robbins)
iv) Lobar form associated with non fusion of central grey matter (T - Unlike semilobar holoprosencephaly, the falx is present, the interhemispheric fissure is fully formed and the thalami are not fused)
3) Best indication of HIE in newborn on MRI is:
i) Increased DWI
ii) Decreased ADC
iii) Increased T2
iv) Decreased T1
v) Decreased NAA on MRS
i) Increased DWI – sensitive (esp. for oedema, seen on DWI before T1/T2), but depends on time since insult. RL: diffusion-weighted imaging scored best for the depiction of infarctions in all groups
3) Best indication of HIE in newborn on MRI is: Radiology Feb 2008 (SK)
i) Increased DWI – sensitive (esp. for oedema, seen on DWI before T1/T2), but depends on time since insult. RL: diffusion-weighted imaging scored best for the depiction of infarctions in all groups
ii) Decreased ADC – does not correlate well with extent of injury or outcome. RL “Normal ADC values thus do not exclude hypoxic-ischemic brain damage in neonates.”
iii) Increased T2 – indicates oedemaiv) Decreased T1 – indicates oedema
v) Decreased NAA on MRS ¬– elevated lactate & decreased NAA (a general MRS marker of necrosis) is a common finding in infants with late neurologic sequelae Radiology Feb 2008: The combination of T1- and T2-weighted imaging and diffusion-weighted imaging is best for the detection of hypoxic-ischemic brain injury in the early neonatal period in term-born infants. Diffusion-weighted imaging is best for depicting infarctions.According to Radiographics, probably best indicator is lactate:choline ratio (elevated, if = 1 then predicts adverse neurodevelopmental outcome)During 1st week → DWIAfter 1st week → pseudonormalisation of DWI, use T1 & T2Indeed, MR spectroscopy and diffusion-weighted MR imaging are the most sensitive imaging modalities for detecting HII in the acute periodStatDx- Use T1WI and PD/Intermediate for identification of deep and periventricular injury - Correlate/verify with DWI and MRS
4) 10yo female. Cystic lesion in midline neck in suprahyoid region. Contains fatty nodules at periphery. Most likely:
i) Thyroglossal duct cyst
ii) 4th branchial cleft cyst
iii) Dermoid
iii) Dermoid
• TGDC = midline when suprahyoid; no fatty nodules
• 4th BCC = against or within superolateral aspect of thyroid gland; off-midline
• Dermoid =Well-defined cyst with fatty material, mixed fluid ± calcification; usually in midline tongue or floor of mouth
• Thymic cyst = lateral infrahyoid neck, almost always on the left.
5) Cystic lesion in child. Feature most supporting lymphangioma over Rannula:
i) Submandibular location
ii) Sublingual location
iii) Parapharyngeal location
iv) Retropharyngeal location
v) Involvement of infrahyoid neck
v) Involvement of infrahyoid neck T – most common site for lymphatic malformation (c.f. Ranula = SLS, involves SMS if ‘diving’)
5) Cystic lesion in child. Feature most supporting lymphangioma over Rannula:
i) Submandibular location F – both can occur here
ii) Sublingual location F lymphatic malformation typically does not involve sublingual space, while ranula always begins in the sublingual space (diving form involves submandibular space) – StatDx
iii) Parapharyngeal location F
iv) Retropharyngeal location F
v) Involvement of infrahyoid neck T – most common site for lymphatic malformation (c.f. Ranula = SLS, involves SMS if ‘diving’)Dahnert
• 75% in posterior triangleStatDx summary:
• Best diagnostic clue: Uni- or multiloculated, non-enhancing, cystic neck mass with imperceptible wall that insinuates between vessels & other normal structures
• Locationo Often found in multiple contiguous spaces, i.e., is trans-spatialo Infrahyoid neck• Posterior cervical space most common spaceo Suprahyoid neck
• Masticator & submandibular spaces most common• Size: Varies from several cm to huge neck mass
• Morphologyo May be unilocular or multilocularo Tends to invaginate between normal structures without mass effect
6) Spondyloepiphyseal dysplasia. NOT a feature:
i) atlanto-occipital instability
ii) kyphosis
iii) normal sized hands and feet
iv) coxa vara
v) normal femoral head ossification
v) normal femoral head ossification F = an “epiphyseal” dysplasia
6) Spondyloepiphyseal dysplasia. NOT a feature:
i) atlanto-occipital instability ?? do get odontoid hypoplasia & atlantoaxial instability
ii) kyphosis T = progressive kyphoscoliosis (Dahnert)
iii) normal sized hands and feet T Short proximal and middle limbs with normal hand and foot size (SED congenita form – StatDx)
iv) coxa vara T = coxa vara, genu valgum, equinovarus foot
v) normal femoral head ossification F = an “epiphyseal” dysplasia