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433
Society
Ontario,
March
abstracts
from
lication. edited
24-26,
the
Abstracts
its
1979, formal
and
Griscom,
abstracts
in
arranged
invited
scientific
N. Thorne
are
was
program
treasurer
conjunction in
the
to
of
for
of the
with
order
submit
the
pubsociety,
authors.
presentation.
for Pediatric
Radiology:
sive Care Unit. Franken JA, Gresham EL, Schreiner Patterns of Evolution Distress Syndrome.
Reducing
Radiation Exposure in Diagnostic AE, Graviss ER, Silberstein MJ
Brodeur
A Comparison of Computed Tomography in the Pediatric Abdomen. Brasch Gooding CA, Filly RA Computed
Tomography
dren.
Harwood-Nash
Radiological Abnormalities Vertebral Soft Tissues Sato Y, Dunbar JS
Fitz
CR,
in ChilS,
Flodmark
0 Post Adenoviral Broncho-Pneumopathy Children. Osborne DR, Becroft
in Infants
and
DM0
Delayed Onset of Right Diaphragmatic Hernia Associated with Group B Streptococcal Infection in the Newborn. McCarten KM, Borden 5, Rosenberg HK, Spackman TJ The Right Heart Culham JA Bilateral
native Colodny
LE,
Pulmonary
Richardson
Ureteroceles: Methods of AH,
in Infancy:
Is Fuzzy
Retik
Hypoplasia
in
Normal?
the
Neonate.
Bauer
AlterRL,
SB
Ultrasound and Computed Tomography of Renal and Penrenal Diseases in Infants and Children: Relationship to Excretory Urography in Renal Cystic Disease, Trauma, and Neoplasms. Bergen PE, Munschauer RW, Kuhn
JP
Corticomedullary Differentiation The tive Phase of Intravenous Pyelography. DK, Lupetin A, Jackson JH Jr
Majd
M,
Evaluation Computed
of Childhood Tomography.
Lithiasis Circulation
Cryptogenic Hepatomegaly Royal SA, Goldberg HI,
Due
Most InformaYousefzadeh
to Interruption of Bile Salts.
Evaluation
of
Biliary
by Thaler
of the Enterohepatic Kirks DR
Atresia
ing 99m-Tc-Sn-PIPIDA. Thomas DW
Miller
in
JH,
Infancy
Utiliz-
Sinatra
FR,
The Complications of Nissen Fundoplication for Gastroesophageal Reflux in Normal and Neurologically Impaired Patients: Radiological Diagnosis. O’Connor JF, Cranley WR, Feins NR, Rubin RR, Cohen GR Mrniography in the Early Prenatal Detection of Thoracic, Lumbar, and Sacral Myelomeningoceles. Gniscom NT, Frigoletto FD, Harris GBC
Jo, Cystic
CJ
Urography as a Guide to Surgical Repair. Lebowitz AB,
in Children.
of Larsen Syndrome from the ‘Anthrogryposis Houston CS, Shokeir MHK, Reed MH
Sonographic
Primary
Swischuk Ectopic
Border
Dystrophy
Separation Basket’.
The
Column Chuang
of the Pharynx and Prein Infectious Mononucleosis.
MM
and Ultrasonography RC, Abols IB,
of the Vertebral DC,
Radiology.
RL
of the Chest X-ray in Respiratory Cleveland RH, Todres D
Reflex Sympathetic McKay DW CONTENTS
1979
Evaluation
Kassnen
Fibrosis:
Abdominal
of the Pediatric
EG, Schneider Its
Ultrasound.
M,
Characteristic Willi
Problems in the Scintigraphic tis in Children. Sullivan J, Gottschalk A
Chest.
Friedman U,
Haller
AP
Appearance Reddish
by Teele
JM,
RL
Detection of OsteomyeliDC, Rosenfield NS, Ogden
Detection of Neonatal Intracranial Hemorrhage: A Comparison of Twenty Patients with Computed Tomography and Ultrasound. Rumack C, Johnson M, Schroeder M, Guggenheim M Abdominal
and
Neonatal Ablow
Hepatic
Necrotizing RC,
Touloukian
Uptake
of
99m-Tc-Pyrophosphate
Enterocolitis RJ,
Matthews
(NEC). T,
Lange
Canide RC
in
VJ,
434
SPR
Reducing
Radiation
Radfoiogy
Silberstein Hospital, For
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Exposure
BrodeurA’E,
comparing systems Cassettes
generally (1200 radiation).
MJ St.
in
ABSTRACTS
Diagnostic
Griv1ssTR,
(Cardinal Glennon Louis, MO 63104)
Memorial
than 5,000 exams we have been two different screen-film imaging in each general diagnostic room. were labeled “A” (200 speed, referred to as par speed) and iiBI more
speed,
requiring
one
sixth
as
much
All “B” screens used were rare earth gadolinium oxysulfide. Above 55kv (three phase), gadolinium phosphors are not kv dependent, so the system is totally compatible with current technical factors. Below 55kv there is only a slight drop-off. All examinations made for alignment purposes (casts, pins, scoliosis, congenital dislocation of the hip, slipped capital femoral epiphysis), and many follow-up examinations (tube progress, cystograms, other pelvic exams) were assigned to the low radiation high speed iiBI system. Difference in image detail between the systems is about 20%; radiographic detail does not follow an inverse one-for-one relationship with speed. We were not hampered by this difference. The result? Approximately 70% reduction in radiation exposure for those examinations
using
the “B” system. More importantly, the needy, multi-repeat, pelvic exam babies receive far less radiation for the same i nformati on A further substitution of new high information, relatively slow speed, screen-
most
film for for
A
systems
25
to
for
100
non-screen
times
those
examinations.
Conparison
of
iTtrasonography
less
Computed in
the
exams
radiation
Tomography Pediatric
Brasch RC, Abols IBGooding (Univ. of California Medical Francisco, CA 94143)
accounts
exposure
and Abdomen:
CA, Filly RA Center, San
Both computed tomography (CT) and gray scale ultrasonography (US) are now being employed to identify, defilie, and differentiate disease processes in children. No comparative clinical study of CT and US in the pediatric abdomen has been reported. Comparisons and principles drawn from the adult experience with either modality cannot reliably be extrapolated to the pediatric population. We have retrospectively reviewed the diagnostic impressions from CT and US of the abdomen in 31 children for whom both US and CT seemed clinically indicated, to compare sensitivity and specificity. The combined information yield from CT and US resulted in correct identification and interpretation of all but three cases. If considered separately, results would have been erroneous in 4 cases with CT and 9 cases with US. There was no difference in the sensitivity of the two imaging modalities. However, overall specificity of diagnosis was greater for CT than US.
AJR:133,
September
1979
Different types of diagnostic information were obtained from CT and US, and the examinations were found to be complementary in many patients. However, considering cost, radiation dose, length of examination, arId accuracy,
to
be
we
Computed in
recommend
followed
by
Tomography
Ch’Tldren:
Chuang’S, Children,
that
CT
if
of
it
US
be
seems
done
first,
necessary.
the
Vertebral Column DC, Fitz CR, 0 (Hospital for Sick ONT M5G lX8)
Harwood-Nash
Tlodmark Toronto,
From a four year experience of computed tomography (CT) in children, we have found that a third body compartment, that of the spinal column and canal, in addition to the brain and visceral cavities of the torso, is most successfully investigated by this modality. We have studied spinal abnormalities at various levels in 400 children, in order to establish the degree of image definition obtained by CT, the normal and abnormal geography at these levels, and the present and future perspective of CT in this compartment. The most common entity studied, that of a dysraphic spine, occurred in 100 children, and neoplasia, either primary or secondary, in 25. We have developed a new radiographic approach: preliminary AP and lateral roentgenographs of the area under investigation, a simple marking device to ascertain precise levels on these and the subsequent CT sections, and CT with or without metrizamide. We suggest that standard roentgenographic tomography, either linear or multi-directional, is not now needed. In some instances, a radionuclide scan can direct the radiologist’s attention to a particular area, and it and CT will often reveal an abnormality not readily identifiable on the standard roentgenographs. CT in different planes provides a clear, accurate, and inclusive demonstration of the vertebrae and surrounding soft tissues, often with only one or two images. We believe this protocol is more accurate, cheaper, and quicker and uses less radiation than prior approaches. The options of intravenous contrast enhancement and spinal CSF opacification make this approach even more effective.
Post Adenoviral anF Children: Univ. Medical
Broncho-Pneumopathy Osborne DR, Becroft Center, Durham, NC
in DM0 27710)
Infants (Duke
In Auckland, New Zealand there were documented epidemics of adenovirus 21 infection of the lower respiratory tract in 1965 and 1977. Eighteen infants and children were reviewed during and six to twelve months after the 1977 epidemic, and 21 were reviewed during and 13 years after the 1965 outbreak. The radiologic patterns in the acute disease were similar in the two epidemics. There
was
widespread
patchy
or and
confluent
pulmonary
opacification
extensive
bronchial streaking.
wall thickening or peribronchial Pulmonary overinflation was
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AJR:133,
september
1979
SPR
common. No hilar adenopathy was demonstrated. Pleural effusions were uncommon; when present, they were small and transient. Six to twelve months after the 1977 epidemic thirteen of fifteen reevaluated patients showed a bronchopulmonary residual. Five had definite bronchiectasis, by high kilovoltage radiography or by bronchography. Of the original 21 patients in the 1965 epidemic, four had died respiratory deaths; post mortem examination demonstrated widespread bronchiectasis. 15 of the survivors were evaluated in 1978; eleven had evidence of significant residual bronchial disease or bronchiectasis, usually follicular or saccul ar. These two epidemics document the importance of adenovirus as a cause of bronchiectasis in children.
Delayed Associated tion in Rosenberg General
Onset of Right Diaphragmatic Hernia with Group B Streptococcal tnf’cthe Newborn: McCarten KM, Borden 5, HK, Spackman TJ (Massachusetts Hospital, Boston, MA 02114)
Over a 1 1/2 year period we have seen five cases of group B streptococcal infection, usually respiratory, in newborns who developed right diaphragmatic hernias later in the first one or two weeks of life. The initial chest radiograph of four patients demonstrated a normal right diaphragmatic margin. The fifth had a right lower lobe infiltrate obscuring a small portion of the right diaphragm. All demonstrated slow elevation of the right hemidiaphragm; in four, this represented only liver; in one, bowel ascended into the right hemithorax. One patient was evaluated with a diagnostic pneumoperitoneum, at which time air immediately flowed into the thorax. At surgery, four children had free pleuro-pulmonary communications, and the fifth had a membrane separating the hernia contents from the pleural space. The basis of this sequence of events is unknown.
435
ABSTRACTS
the major fissure seemed to be the basis of the finding. In the other six infants, small foci of pneumonia or atelectasis found in the medial segment of the middle lobe accounted for the lack of a sharp mediastinal Si 1 houette. Thus poor delineation of the right heart border seems usually to be abnormal.
Bilateral Primary Pulmonary Ilypoplasia in the Neonate: Swischuk LE, Richardson CJ (Child Health Center, The Univ of Texas Fledical Branch, Galveston, TX 77550) Bilateral primary pulmonary hypoplasia probably is more common than is generally appreciated. We present eight such cases. The infants had respiratory distress from birth. Roentgenographically they demonstrated persistently small, clear lungs. They had no other abnormalities and no evidence of the fetal compression syndrome. The persistent fetal circulation syndrome was a common complicating feature (7 of 8 cases), and attention was often first focused n the cardiovascular system. Pneumothorax and pneumomediastinum were common (7 of 8), The more severely afflicted infants died shortly after birth. Autopsy (4 cases) demonstrated small lungs, both by size and weight, and decreased radial alveolar counts. Those who survived the first few days of life (2 cases) soon became well. Early diagnosis in this condition is most elusive, for there is reluctance to ascribe the symptoms to hypoplasia. Possibly diminished respiratory activity inutero is part of the cause.
Ectopic Ureteroceles: Urography as a Guide to Alternative MethodsThf Surgical Repair: Lebowitz RL, Colodny H, Retik AB, Bauer SB (Children’s Hospital Medical Center, Boston, MA 02115)
Radiologists differ tion of a poorly defined in children in the first
in their interpretaright heart border year of life. Many
The term ectopic ureterocele is neither anatomically nor clinically precise. The involved kidney may have mild or severe obstruction or dysplasia of the upper moiety, and either a normal lower pole or any degree of reflux affecting the lower unit. Large or prolapsed ureteroceles may obstruct the adjacent lower pole ureter, the opposite ureter, or the bladder outlet. No single method of treatment is appropriate for all these situations. Alternative
regard
normal,
methods
The Right Normal?: Children,
it
such
Heart Border in Infancy: Cuiham JA (The Hospital Toronto, Ont M5G lX8)
a
finding
as
Is for
others
Fuzzy Sick
think
abnormal, and still others vacillate. We performed computerized tomographic scans of the lower thorax in ten infants with an ill-defined right heart border but normal lateral films. All had symptoms of respiratory infection. Scan time was 2 1/2 minutes. Two scans were unsatisfactory because of the long scan time. In one child, a large, low, obliquely oriented thymus covered the heart, prevented a mediastinal tangent on the frontal film, and accounted for the fuzzy heart border. In another child, a small collection of fluid in the medial part of
of
1
.
2.
3.
4.
surgical
repair
include:
Incision of the ureterocele, a largely outmoded approach. Upper pole heminephrectomy and ureterectomy, excision of the ureterocele, and reimplantation of the lower pole ureter. Upper pole heminephrectomy and ureterectomy, the decompressed ureterocele being left in the bi adder. Upper to lower uretero-ureterostomy, the decompressed ureterocele being left in the bladder.
436
SPR
5.
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The selected anatomic determined
Excision of the ureterocele and common-sheath reimpl antati on. operative procedure should be on the basis of the underlying and physiologic abnormalities as by IVP and VCUG.
Ultrasound and Computed Tomography and Perirenal Diseases in Infants Children: RelationshiptoExcretory in RenaT Cystic_Disease, Trauma Neopiasms: Berger PEI Munschauer Kuhn JP (Children’s Hospital of Buffalo, NY 14222)
of aid
Renal
Urograpy and RW, Buffalo,
47 infants and children had excretory urography, ultrasound, and computed tomographic examinations with the renal and penrenal areas as primary regions of interest. Ultrasound is an excellent screening procedure, may often be diagnostic, and may be the only imaging examination necessary. We have found this to be the case with suspected renal cystic disease and recommend ultrasound as the initial procedure. The excretory urogram may be inaccurate, as was the case in 4 of 14 patients, and is often unnecessary. Computed tomography can provide superior anatomic detail and measure tissue densities. This makes it the imaging procedure which best demonstrates the extent of renal injury (often grossly underestimated by excretory urography) and best delineates the character and extent of solid renal and penirenal neoplasms. For children with solid tumors of the retropenitoneal area, we feel CT is not only justified (after screening by ultrasound) but is the definitive examination. Excretory urography is often unnecessary in these conditions.
Corticomedullary Differentiation The Most Informative Phase of Intravenous yelography: Yousefzadeh DK, Lupetin A, Jackson JH, Jr. (Univ. of Iowa Hospitals and Clinics, Iowa City, IA 52242) Since renal cortical blood flow is considerably greater than that of either the penirenal structures or medulla, the maximal differentiation of the cortex from its inner and outer neighbors is achieved 4 or 5 seconds after completion of rapid injection of contrast medium through one or two upper extremity veins. The high-quality image during this transient period of corticomedullary differentiation often resembles an excellent coronal cut of the kidney cortex, despite such well known obstacles as bowel gas and feces. The image deteriorates as the time of the first exposure approaches the total body opacification phase and thereafter. The clarity of the renal outline and its architecture diminishes because of fading of kidney density and corticomedullary differentiation. The vascular anatomy, often surprisingly well shown by this technique, is an added bonus. Sometimes arteniography is obviated. Even tumor vessels may be seen.
ABSTRACTS
AJR:133,
September
1979
Two to four images at intervals of 1 or seconds can be obtained while a 14 x 17 cassette parked in a Bucky tray is manually advanced cephalad once or twice or three times, over 1/2 or 1/3 or 1/4 of its length, until it is fully exposed. This technique has made tomography unnecessary. Cleansing enemas and carbonated beverages are avoided. The dose of the contrast medium and the radiation dose need not exceed those of conventional methods.
:
Routine Lateral Chest 1eonata1 IntensiveCare Vu P, Smith WL, Smith Schreiner RL (Indiana Indianapolis, IN 46202)
Radiogra h in the Unit: rankenEA, JA, Gresham EL, Univ. School of 1ledicine,
This study was designed to assess the diagnostic efficacy of the routine lateral chest film in symptomatic newborn infants. AP and cross-table lateral chest radiographs were done in 53 consecutive patients upon admission to the newborn intensive care unit. Subsequently three radiologists and two neonatologists performed blind, independent analyses of the films with and without the lateral film. A total of 530 sets of observations (53 x 5 x 2) were performed. Assessment of lung inflation and discovery of abnormalities of the heart, mediastinum, and trachea were unaffected by the use of the lateral radiograph. A correct primary diagnosis was made in 74% o all cases by the AP chests alone and in 71% by the AP-lateral series. Analysis of the AP chest alone compared to the AP-lateral series showed no difference in diagnostic accuracy. Degree of confidence in the primary diagnosis did not change when the lateral chest radiograph was added. There was no appreciable difference in the detection of complications of the primary disease. We conclude that the risks (radiation, environmental disturbance) of the routine admitting lateral chest radiograph are substantially greater than any benefits to be gained.
Patterns of Evolution of theChest Rej1ratory Distress Sndime: Todres D (Massachusetts iene’-al Harvard Medical School, Boston,
X-ray Cleveland Hospital, MA 02114)
in RH,
Since bronchopulmonary dysplasia was first described as a complication of hyaline membrane disease, much attention has been given to the “white out phase, which has generally been interpreted as an ominous development. In a series of 110 newborns admitted to our intensive care unit in a 2 1/2 year period, there were 21 children showing 22 instances of pulmonary iiwhite out, radiographically consistent with Northway’s stage II bronchopulmonary dysplasia. However, only 11 (50%) of these occurred in critically ill infants. All 11 were receiving close to 100% 02, and perhaps their iiwhite out” is explained by the resorp-
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AJR: 133, September
SPR
1979
tive atelectasis known to occur with hightension 02 administration. The other 11 children developed their “white out” as they were being weaned from the ventilator. In most of these infants, the radiograph showing the “white out” was obtained shortly after a significant decrease in artificial ventilatory pressure. In all 11 a more normally aerated chest was documented shortly after the “white out”. A similar transient, innocuous process has recently been demonstrated in adults and results from a decrease in ventilatory pressures.
Radiological Abnormalities of the_Phry,.. Pre-Vertebral Soft Tissues fn Infectious Mononucleosis: Sato Y, DunbarR’TChi1dren’s Hospital Medical Center, Cincinnati OH
Dystrophy in Children: (CTiildren’s Hospital Center, Washington, DC
437
In eight cases the radionuclide bone scans showed decreased blood flow to the involved extremity and decreased uptake of radionuclide in the bones. The other two children showed increased blood flow and juxtaarticular increase in uptake, similar to the pattern reported in adults with this syndrome. The bone scans helped in establishing the diagnosis and in excluding other causes of extremity pain. Separation of Larsen Syndrome from the ‘Arthrogryposis BaskeF: Houston CS, Shokeir MHK, Reed MH (Univ. Hospital Saskatoon, SASK S7H 0W8) and
45229)
Infectious mononucleosis may cause inflammatory swelling of the adenoids, the tonsils, or the cervical pre-vertebral soft tissues. The adenoid enlargement may be so severe as completely to occlude the nasopharynx and obstruct nasal breathing. The tonsils may be so large as to cause difficulty in breathing, and urgent tonsillectomy is occasionally required. The pre-vertebral soft tissue swelling does not cause respiratory obstruction. Review of 92 cases of infectious mononucleosis uncovered 7 children with upper airway obstruction. In each case radiographs demonstrated marked enlargement of the adenoids or tonsils or both, sometimes plus thickening of the pre-vertebral soft tissues. The larynx and trachea were not involved. Although the findings are not specific for or diagnostic of infectious mononucleosis, it is sometimes possible to suggest the diagnosis from the radiologic findings. Conversely, when a child with known infectious mononucleosis has difficulty with nasal or oral respiration or with swallowing, radiologic findings may indicate the site and severity of the obstruction. The swelling and the symptoms commonly abate with corticosteroids.
Reflex Sympathetic Majd M, FicKay DW National Medical
ABSTRACTS
20010)
The reflex sympathetic dystrophy syndrome consists of pain, hyperesthesia, vasomotor instability, and trophic skin changes in an extremity. It usually is associated with antecedent trauma. Though well known in adults, the syndrome is rarely diagnosed in children, who are often misdiagnosed as having psychiatric problems. Over the past three years we have seen ten such children. All these children had unexplained severe pain in the affected extremity. Vasomotor phenomena, such as temperature changes, were frequently overlooked at first. Radiographs were invariably normal except for osteoporosis in one case. Laboratory data were not helpful.
Arthrogryposis multiplex congenita is a heterogeneous symptom-complex. The term “arthrogryposis” does not imply etiology, does not assist in management, and does not shed light on prognosis. Larsen syndrome is one of a number of entities that have masqueraded under the heading of arthrogryposis. We report five cases. All had multiple dislocations. At least four had abnormalities of the spine. Three had equinovarus deformities, and the other two had other abnormalities of the feet. Both of the children whose wrists were examined had extra carpal bones. All five had flattening of the face, and some had orbital hypertelorism. Some had stiff joints, but others had excessively mobile joints. If our experience is at all representative, there must be hundreds of cases of Larsen syndrome, many misdiagnosed as arthrogryposis, in the files of other hospitals. Evaluation of Childhood C.y.ptogenic Hepatomegaly by Computed Toriograhy: Roy&F SA, Goldberg HI, Thaler MM (Univ of California, San Francisco, CA 94143) Computed tomography (CT) of the liver in 10 children with anicteric hepatomegaly mdicated that CT numbers often indicate the type of intrahepatic deposit responsible. CT numbers were 50-60 (old Hounsfield numbers) in 5 patients with hemochromatosis due to multiple transfusions for thalassemia, 32-40 in 3 patients with glycogen storage disease, and -5 and +5 in 2 with fatty liver due to Cushing’s disease and lipoprotein lipase deficiency respectively. CT numbers in 40 children with normal liver size and functions ranged from 12 to 32. CT numbers in 100 normal adults ranged from 16 to 34. To determine the sensitivity of CT to liver fat, fatty liver was produced in 4 dogs by surgical pancreatectomy. Each was monitored with serial CT scans and histological and quantitative triglyceride analyses of serial percutaneous liver biopsies. Changes were seen on CT images within 6 to 8 hours of pancreatectomy. The maximal decline in mean liver CT number (21 units) corresponded to an increase in liver triglyceride content from 1% to 22% of wet weight. Vigorous insulin therapy caused histological and quantitative reversal of fatty liver and return of the liver CT number to normal.
SPR
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438
ABSTRACTS
AJR:133,
September
1979
These results indicate that CT can be a sensitive, relatively specific, non-invasive tool for the diagnosis of cryptogenic hepatomegaly.
of this agent by the liver and the vastly improved imaging statistics make JYfl1Tc_ PIPIDA a desirable agent for the evaluation of biliary excretion disorders in infancy.
Lithiasis Due to Interruption hepatic Circulation of Bile (Children’s Medical Center,
The Complications of Nissen Fundoplication for Gastro&sophageiTRefTuxjn Normal and Neurolojically Impaired Patient: Radiological Di agnosi s : 0’ Connor JF, CiInl ey WR, Feins NR, Rubin RR, Cohen GR (Boston Univ. School of Medicine, Boston, MA 02118)
of the Salts: Dallas,
EnteroKirks DR TX 75235)
Bile salts are formed from cholesterol and are conjugated in the liver, excreted via the biliary system into the duodenum, reabsorbed in the ileum, stored temporarily in the hepatic bile salt pool, and re-excreted into the biliary system. We report two children in whom interruption of this enterohepatic circulation led to stone formation. In one child, ileal dysfunction due to surgical resection because of midgut volvulus led to failure of absorption of bile salts, depletion of hepatic bile salts, accumulation of cholesterol in bile, and cholesterol cholel ithiasis. In another child, ileal dysfunction due to regional enteritis led to failure of absorption of bile salts, an increase in the quantity of bile salts presented to the colon, enzymatic lysis of these salts to oxalate, absorption into the blood stream, hyperoxaluria, and an oxalate ureteral stone. Other possible mechanisms in this child include steatorrhea leading to decrease in intraluminal calcium for binding ingested oxalate, and a direct effect of unabsorbed bile salts on the colon increasing oxalate absorption. Ileal dysfunction and interruption of the enterohepatic circulation of bile salts must be added to the causes of childhood biliary and urinary lithiasis. The Evaluation Utilizing Sinatra FRThomas of Los Angeles,
of
Biliary
Atresia inInfan,y. Miller JH, DW (Children’s Hospital Los Angeles, CA 90027)
A new class of hepatobiliary imaging agents has become available; these are the Nsubstituted iminodiacetic acids. Following intravenous administration, these compounds are quickly extracted by the hepatocytes and rapidly excreted into the biliary tree. By utilizing a 99mTc label sufficient activity may be given to allow excellent gamma camera imaging. We have utilized 99mTc_labelled pisopropylacetanilido-iminodiacetic acid (PIPIDA) in the evaluation of two children suspected of having biliary atresia; in neither did the isotope appear in the gut, which correctly supported that diagnosis. In five patients we have evaluated the patency of surgically created portico-enterosmies (Kasai anastoriloses); in all five the mTc_ Sn-PIPIDA study accurately assessed patency. In comparison with the previously available agent (l3lI-Rose Bengal), the marked reduction in radiation to the liver alone should predicate the use of 9YmTc_ PIPIDA. In addition, the speed of handling
Surgical intervention for gastroesophageal reflux in infancy and childhood has become more common in the past several years. Minor complications of Nissen fundoplication include dysphagia, the “gas bloat” syndrome, inability to vomit, and “colic”. Major complications include anastomotic leaks, recurrent reflux and esophagitis, impaction of food or other forei gn body , dehi scence of the Nissen sutures, partial or complete “slipping,” injury to the spleen (occasionally requiring splenectomy), subphrenic abscess, empyema , mediasti ni ti s , pericardi ti s, fistulae, and wound infections. The role of the radiologist in most of these is evident. The authors suggest that the r.iechanism of the “slipped” Nissen is herniation of the posterior fold created by the wrapped fundus. This results in an hour-glass deformity, recurrent reflux, and occasional obstruction at the site of the deformity.
Amniography in theEarly Prenatal Detection of Thoracic, Lumbar, and SiraI MyeloiiieniWoceles: Griscm NT, Frigoletto FD, Harris GBC (Harvard Medical School, Boston, MA 02115) The family history and the maternal serum level of alpha-fetoprotein (AFP) are current screening methods for fetal myelomeningocele. Amniotic fluid AFP, ultrasonography, and amniography are the available confirmatory tests. Amniotic fluid AFP can be misleadingly positive in a variety of congenital disorders, fetal distress, contamination of the sample by fetal blood, and in normals at the high end of the standard distribution curve. Even with advanced techniques, ultrasonography may miss both a myelomeningocele sac and posterior vertebral splaying before 20 weeks. We report the amniographic examination, performed at an average of 18 weeks, of 28 fetuses. The indications were affected family members (usually an older sibling of the fetus), elevated AFP, or both. Fifteen to 30 cc. of 60% diatrizoate were injected. The end-point of the examination was a tangent view of the fetal back on a fluoroscopic spot film to show the presence or absence of a midline bulging mass outlined by the opacified amniotic fluid. Computed from phantom dosimetry, fetal irradiation was 0.66 ± .36 rads. There were 26 true negatives. Our one true positive occurred in a woman with elevated serum and amniotic fluid AFP but negative real-time ultrasonography. In the
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AJR:133, September
SPR
1979
twenty-eighth case the question of meningocele could not be answered, of polyhydramnios and dilution due duodenal atresia. We suggest that amniography be amniotic fluid AFP and ultrasonography disagree and for further certainty those tests are positive. Sonographic Evaluation HalTer JO, Kissner EG, Friedman AP (Downstate Brooklyn, NY 11203)
of the Schneidir Medical
myelobecause to used when
Pediatric N, Center,
when both
Chest:
Gray-scale sonography was performed in 28 pediatric patients with chest disease (age range: 3 days to 16 years). Sonography was very useful in the evaluation of diaphragmatic and juxtadiaphragmatic disorders such as extrapleural abscess, loculated subpulmonic effusion, ectopic kidney, ectopic spleen and diaphragmatic paralysis. In patients with an opaque hemithorax it was possible to distinguish parenchymal consolidation (inflammatory and neoplastic), pleural effusion, pleural thickening and massive cardiomegaly. Several types of anterior mediastinal and juxtacardiac masses were accurately depicted. In 5 patients it was possible to drain extrapleural abscesses following sonographic localization. Sonography is most useful for disease processes abutting the chest wall, since it is generally possible to demonstrate the interface with adjacent normal structures (heart, diaphragm, liver, air-filled lung). Although the heart can be used as a “window” into the middle and posterior mediastinum, we found sonography to be of only moderate value for masses and fluid collections in these locations. We found it impossible to distinguish a normal thymus from one involved by tumor by ultrasound. Cystic Fibrosis: Its Characteristic Appearance by Abdominal Ultrasound: Wilfl U, Reddish JM, Teele RL (Children’s Hospital Medical Center, Boston, MA 02115) We patients the ages expected, involving
reviewed the ultrasonic scans of 24 with cystic fibrosis who were between of 8 and 30 years. There was, as a high incidence of abnormalities the
liver
and
biliary
tree,
including cholelithiasis, cirrhosis, obstruction of the common bile duct, and microgallbladder. The scans also demonstrated splenomegaly and dilatation of the superior mesenteric vein in the presence of portal hypertension. Other findings were infiltration of the pancreas by fat or fibrosis with reduction of its size, enlargement of the pancreas in two cases of pancreatitis, thickening of the wall of the stomach and duodenum, and congestion of the hepatic veins and inferior vena cava. Problems in the Scintigraphic Detection of Osteomyelitis in Children: Sullivan DC, Rosen’field 45, Ogden J, Gottschalk A (NSR Yale Univ. School of Medicine, New haven, CT 06510)
ABSTRACTS
439
Bone scintigraphy with 99n’Tc-labelled compounds is recognized as a useful test for detection of acute hematogenous osteomyelitis in children. Recent studies have reported accuracies ranging from 84 to 100%. Furthermore, the text and figures in many of these papers indicate that the scintigraphic appearance of pediatric osteomyelitis is usually obvious and easily interpreted. Our cases of osteomyelitis in children are usually treated with surgical drainage, which enables us to correlate the scintiphotos with operative findings. The results of our experience differ in several respects from those reported by others. 99mTc_pyrophosphate studies in 21 children with acute hematogenous osteomyelitis were compared with radiographic, clinical, and surgical findings. Eleven scintigraphic studies revealed obvious abnormalities, 3 showed subtle abnormalities, 2 falsely suggested septic arthritis by symmetrical uptake surrounding the joint, and 5 (including 2 newborns) were normal. Two of the false negatives simultaneously had positive roentgenograms. No consistent explanation for the lack of positive isotope findings was found. We conclude that pediatric osteomyelitis represents a spectrum of scintigraphic appearances; interpretation is often difficult. Detection of Neonatal Intracranial Hemorrhage: A Comparison of Twenty Patients with. Computed Tomography and Uftrasou1: ‘Riithick C, Johnson M, Schroeder M, Guggenheim M (Denver General Hospital and Univ. of Colorado Medical Center, Denver, CO 80204) Neonatal intracerebral hemorrhage is now one of the primary factors in the morbidity and mortality of premature infants. Computed tomographic scanning has become the definitive method of diagnosis of this entity. A comparison of ultrasound to computed tomographic scanning was made in 19 premature infants to determine the feasibility and accuracy of diagnosing hemorrhage with ultrasound and the agreement on hemorrhage site and ventricular size between ultrasound and computed tomography. The ratio of ventricular size to hemispheric size can be obtained with either method. In most of our cases, the ventricular size was lower by computerized tomographic scanning than by ultrasound, perhaps because of computer averaging of the data, although differences were small. Intraventricular hemorrhages can be seen by either method. However, intracerebral hemorrhage and subarachnoid hemorrhage can be diagnosed reliably only by computed tomography. In our opinion, the initial diagnosis of the site of the bleed must be done with computed tomographic scanning. The followup evaluation can be done using the latest ultrasound equipment; this can show the most common complications, hydrocephalus and porencephaly. This approach computed tomography initially, followed by ultrasound
-
440
SPA
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is clearly invasive lowering
the most cost-effective, system, and results in a of the radiation dose to
ABSTRACTS
nonsignificant the infant.
Abdominal and Hepatic Uptake of 99mTc_ yrophosphate fn KeonaIal NecrotTzT#{241}9 Enterocolitis (NIC): Caride VJ, Ablow RC, Touloukian RJ, Matthews T, Lange RC (Yale Univ. School of Medicine, New Haven, CT 06510) 99mTc been
pyrophosphate
(99mTcpYp)
has
shown to concentrate in infarcted tissues. Eleven neonates with the clinical suspicion of NEC were studied with this agent. Also included in this study were two newborns with osteomyelitis and one newborn with myocarditis. One to four scintigrams were performed during the course of the infants’ disease. The scans were evaluated for abdominal uptake (localized or diffuse) or liver uptake and were correlated with serial abdominal x-rays and clinical factors.
AJR:133,
September
1979
Of the eleven babies with clinical suspicion of NEC, nine had abdominal uptake and seven had liver uptake, though only four had definite intramural air by radiography. In the two babies with osteomyelitis, the abdominal scintigrams were normal. The neonate with myocarditis had liver uptake and questionable abdominal uptake, for unknown reasons. In infants with sequential scans, there was a correlation between the return to normal of the clinical and radiographic signs and the scintigraphic findings. Although total or diffuse abdominal uptake of 93mTcpYp can be explained on the basis of gut or peritoneal involvement, there is no satisfactory explanation for the hepatic uptake. The quality of the radio-pharmaceutica was checked; more than 90% of the 9r.ITc activity was ggmTcpYp, ruling out the presence of appreciable quantities of colloid. The results suggest that abnormal abdominal or liver uptake of 9YmTcPYP may prove valuable as an index of continuing or resolving NEC.
433
Society
Ontario,
March
abstracts
from
lication. edited
24-26,
the
Abstracts
its
1979, formal
and
Griscom,
abstracts
in
arranged
invited
scientific
N. Thorne
are
was
program
treasurer
conjunction in
the
to
of
for
of the
with
order
submit
the
pubsociety,
authors.
presentation.
for Pediatric
Radiology:
sive Care Unit. Franken JA, Gresham EL, Schreiner Patterns of Evolution Distress Syndrome.
Reducing
Radiation Exposure in Diagnostic AE, Graviss ER, Silberstein MJ
Brodeur
A Comparison of Computed Tomography in the Pediatric Abdomen. Brasch Gooding CA, Filly RA Computed
Tomography
dren.
Harwood-Nash
Radiological Abnormalities Vertebral Soft Tissues Sato Y, Dunbar JS
Fitz
CR,
in ChilS,
Flodmark
0 Post Adenoviral Broncho-Pneumopathy Children. Osborne DR, Becroft
in Infants
and
DM0
Delayed Onset of Right Diaphragmatic Hernia Associated with Group B Streptococcal Infection in the Newborn. McCarten KM, Borden 5, Rosenberg HK, Spackman TJ The Right Heart Culham JA Bilateral
native Colodny
LE,
Pulmonary
Richardson
Ureteroceles: Methods of AH,
in Infancy:
Is Fuzzy
Retik
Hypoplasia
in
Normal?
the
Neonate.
Bauer
AlterRL,
SB
Ultrasound and Computed Tomography of Renal and Penrenal Diseases in Infants and Children: Relationship to Excretory Urography in Renal Cystic Disease, Trauma, and Neoplasms. Bergen PE, Munschauer RW, Kuhn
JP
Corticomedullary Differentiation The tive Phase of Intravenous Pyelography. DK, Lupetin A, Jackson JH Jr
Majd
M,
Evaluation Computed
of Childhood Tomography.
Lithiasis Circulation
Cryptogenic Hepatomegaly Royal SA, Goldberg HI,
Due
Most InformaYousefzadeh
to Interruption of Bile Salts.
Evaluation
of
Biliary
by Thaler
of the Enterohepatic Kirks DR
Atresia
ing 99m-Tc-Sn-PIPIDA. Thomas DW
Miller
in
JH,
Infancy
Utiliz-
Sinatra
FR,
The Complications of Nissen Fundoplication for Gastroesophageal Reflux in Normal and Neurologically Impaired Patients: Radiological Diagnosis. O’Connor JF, Cranley WR, Feins NR, Rubin RR, Cohen GR Mrniography in the Early Prenatal Detection of Thoracic, Lumbar, and Sacral Myelomeningoceles. Gniscom NT, Frigoletto FD, Harris GBC
Jo, Cystic
CJ
Urography as a Guide to Surgical Repair. Lebowitz AB,
in Children.
of Larsen Syndrome from the ‘Anthrogryposis Houston CS, Shokeir MHK, Reed MH
Sonographic
Primary
Swischuk Ectopic
Border
Dystrophy
Separation Basket’.
The
Column Chuang
of the Pharynx and Prein Infectious Mononucleosis.
MM
and Ultrasonography RC, Abols IB,
of the Vertebral DC,
Radiology.
RL
of the Chest X-ray in Respiratory Cleveland RH, Todres D
Reflex Sympathetic McKay DW CONTENTS
1979
Evaluation
Kassnen
Fibrosis:
Abdominal
of the Pediatric
EG, Schneider Its
Ultrasound.
M,
Characteristic Willi
Problems in the Scintigraphic tis in Children. Sullivan J, Gottschalk A
Chest.
Friedman U,
Haller
AP
Appearance Reddish
by Teele
JM,
RL
Detection of OsteomyeliDC, Rosenfield NS, Ogden
Detection of Neonatal Intracranial Hemorrhage: A Comparison of Twenty Patients with Computed Tomography and Ultrasound. Rumack C, Johnson M, Schroeder M, Guggenheim M Abdominal
and
Neonatal Ablow
Hepatic
Necrotizing RC,
Touloukian
Uptake
of
99m-Tc-Pyrophosphate
Enterocolitis RJ,
Matthews
(NEC). T,
Lange
Canide RC
in
VJ,
434
SPR
Reducing
Radiation
Radfoiogy
Silberstein Hospital, For
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Exposure
BrodeurA’E,
comparing systems Cassettes
generally (1200 radiation).
MJ St.
in
ABSTRACTS
Diagnostic
Griv1ssTR,
(Cardinal Glennon Louis, MO 63104)
Memorial
than 5,000 exams we have been two different screen-film imaging in each general diagnostic room. were labeled “A” (200 speed, referred to as par speed) and iiBI more
speed,
requiring
one
sixth
as
much
All “B” screens used were rare earth gadolinium oxysulfide. Above 55kv (three phase), gadolinium phosphors are not kv dependent, so the system is totally compatible with current technical factors. Below 55kv there is only a slight drop-off. All examinations made for alignment purposes (casts, pins, scoliosis, congenital dislocation of the hip, slipped capital femoral epiphysis), and many follow-up examinations (tube progress, cystograms, other pelvic exams) were assigned to the low radiation high speed iiBI system. Difference in image detail between the systems is about 20%; radiographic detail does not follow an inverse one-for-one relationship with speed. We were not hampered by this difference. The result? Approximately 70% reduction in radiation exposure for those examinations
using
the “B” system. More importantly, the needy, multi-repeat, pelvic exam babies receive far less radiation for the same i nformati on A further substitution of new high information, relatively slow speed, screen-
most
film for for
A
systems
25
to
for
100
non-screen
times
those
examinations.
Conparison
of
iTtrasonography
less
Computed in
the
exams
radiation
Tomography Pediatric
Brasch RC, Abols IBGooding (Univ. of California Medical Francisco, CA 94143)
accounts
exposure
and Abdomen:
CA, Filly RA Center, San
Both computed tomography (CT) and gray scale ultrasonography (US) are now being employed to identify, defilie, and differentiate disease processes in children. No comparative clinical study of CT and US in the pediatric abdomen has been reported. Comparisons and principles drawn from the adult experience with either modality cannot reliably be extrapolated to the pediatric population. We have retrospectively reviewed the diagnostic impressions from CT and US of the abdomen in 31 children for whom both US and CT seemed clinically indicated, to compare sensitivity and specificity. The combined information yield from CT and US resulted in correct identification and interpretation of all but three cases. If considered separately, results would have been erroneous in 4 cases with CT and 9 cases with US. There was no difference in the sensitivity of the two imaging modalities. However, overall specificity of diagnosis was greater for CT than US.
AJR:133,
September
1979
Different types of diagnostic information were obtained from CT and US, and the examinations were found to be complementary in many patients. However, considering cost, radiation dose, length of examination, arId accuracy,
to
be
we
Computed in
recommend
followed
by
Tomography
Ch’Tldren:
Chuang’S, Children,
that
CT
if
of
it
US
be
seems
done
first,
necessary.
the
Vertebral Column DC, Fitz CR, 0 (Hospital for Sick ONT M5G lX8)
Harwood-Nash
Tlodmark Toronto,
From a four year experience of computed tomography (CT) in children, we have found that a third body compartment, that of the spinal column and canal, in addition to the brain and visceral cavities of the torso, is most successfully investigated by this modality. We have studied spinal abnormalities at various levels in 400 children, in order to establish the degree of image definition obtained by CT, the normal and abnormal geography at these levels, and the present and future perspective of CT in this compartment. The most common entity studied, that of a dysraphic spine, occurred in 100 children, and neoplasia, either primary or secondary, in 25. We have developed a new radiographic approach: preliminary AP and lateral roentgenographs of the area under investigation, a simple marking device to ascertain precise levels on these and the subsequent CT sections, and CT with or without metrizamide. We suggest that standard roentgenographic tomography, either linear or multi-directional, is not now needed. In some instances, a radionuclide scan can direct the radiologist’s attention to a particular area, and it and CT will often reveal an abnormality not readily identifiable on the standard roentgenographs. CT in different planes provides a clear, accurate, and inclusive demonstration of the vertebrae and surrounding soft tissues, often with only one or two images. We believe this protocol is more accurate, cheaper, and quicker and uses less radiation than prior approaches. The options of intravenous contrast enhancement and spinal CSF opacification make this approach even more effective.
Post Adenoviral anF Children: Univ. Medical
Broncho-Pneumopathy Osborne DR, Becroft Center, Durham, NC
in DM0 27710)
Infants (Duke
In Auckland, New Zealand there were documented epidemics of adenovirus 21 infection of the lower respiratory tract in 1965 and 1977. Eighteen infants and children were reviewed during and six to twelve months after the 1977 epidemic, and 21 were reviewed during and 13 years after the 1965 outbreak. The radiologic patterns in the acute disease were similar in the two epidemics. There
was
widespread
patchy
or and
confluent
pulmonary
opacification
extensive
bronchial streaking.
wall thickening or peribronchial Pulmonary overinflation was
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AJR:133,
september
1979
SPR
common. No hilar adenopathy was demonstrated. Pleural effusions were uncommon; when present, they were small and transient. Six to twelve months after the 1977 epidemic thirteen of fifteen reevaluated patients showed a bronchopulmonary residual. Five had definite bronchiectasis, by high kilovoltage radiography or by bronchography. Of the original 21 patients in the 1965 epidemic, four had died respiratory deaths; post mortem examination demonstrated widespread bronchiectasis. 15 of the survivors were evaluated in 1978; eleven had evidence of significant residual bronchial disease or bronchiectasis, usually follicular or saccul ar. These two epidemics document the importance of adenovirus as a cause of bronchiectasis in children.
Delayed Associated tion in Rosenberg General
Onset of Right Diaphragmatic Hernia with Group B Streptococcal tnf’cthe Newborn: McCarten KM, Borden 5, HK, Spackman TJ (Massachusetts Hospital, Boston, MA 02114)
Over a 1 1/2 year period we have seen five cases of group B streptococcal infection, usually respiratory, in newborns who developed right diaphragmatic hernias later in the first one or two weeks of life. The initial chest radiograph of four patients demonstrated a normal right diaphragmatic margin. The fifth had a right lower lobe infiltrate obscuring a small portion of the right diaphragm. All demonstrated slow elevation of the right hemidiaphragm; in four, this represented only liver; in one, bowel ascended into the right hemithorax. One patient was evaluated with a diagnostic pneumoperitoneum, at which time air immediately flowed into the thorax. At surgery, four children had free pleuro-pulmonary communications, and the fifth had a membrane separating the hernia contents from the pleural space. The basis of this sequence of events is unknown.
435
ABSTRACTS
the major fissure seemed to be the basis of the finding. In the other six infants, small foci of pneumonia or atelectasis found in the medial segment of the middle lobe accounted for the lack of a sharp mediastinal Si 1 houette. Thus poor delineation of the right heart border seems usually to be abnormal.
Bilateral Primary Pulmonary Ilypoplasia in the Neonate: Swischuk LE, Richardson CJ (Child Health Center, The Univ of Texas Fledical Branch, Galveston, TX 77550) Bilateral primary pulmonary hypoplasia probably is more common than is generally appreciated. We present eight such cases. The infants had respiratory distress from birth. Roentgenographically they demonstrated persistently small, clear lungs. They had no other abnormalities and no evidence of the fetal compression syndrome. The persistent fetal circulation syndrome was a common complicating feature (7 of 8 cases), and attention was often first focused n the cardiovascular system. Pneumothorax and pneumomediastinum were common (7 of 8), The more severely afflicted infants died shortly after birth. Autopsy (4 cases) demonstrated small lungs, both by size and weight, and decreased radial alveolar counts. Those who survived the first few days of life (2 cases) soon became well. Early diagnosis in this condition is most elusive, for there is reluctance to ascribe the symptoms to hypoplasia. Possibly diminished respiratory activity inutero is part of the cause.
Ectopic Ureteroceles: Urography as a Guide to Alternative MethodsThf Surgical Repair: Lebowitz RL, Colodny H, Retik AB, Bauer SB (Children’s Hospital Medical Center, Boston, MA 02115)
Radiologists differ tion of a poorly defined in children in the first
in their interpretaright heart border year of life. Many
The term ectopic ureterocele is neither anatomically nor clinically precise. The involved kidney may have mild or severe obstruction or dysplasia of the upper moiety, and either a normal lower pole or any degree of reflux affecting the lower unit. Large or prolapsed ureteroceles may obstruct the adjacent lower pole ureter, the opposite ureter, or the bladder outlet. No single method of treatment is appropriate for all these situations. Alternative
regard
normal,
methods
The Right Normal?: Children,
it
such
Heart Border in Infancy: Cuiham JA (The Hospital Toronto, Ont M5G lX8)
a
finding
as
Is for
others
Fuzzy Sick
think
abnormal, and still others vacillate. We performed computerized tomographic scans of the lower thorax in ten infants with an ill-defined right heart border but normal lateral films. All had symptoms of respiratory infection. Scan time was 2 1/2 minutes. Two scans were unsatisfactory because of the long scan time. In one child, a large, low, obliquely oriented thymus covered the heart, prevented a mediastinal tangent on the frontal film, and accounted for the fuzzy heart border. In another child, a small collection of fluid in the medial part of
of
1
.
2.
3.
4.
surgical
repair
include:
Incision of the ureterocele, a largely outmoded approach. Upper pole heminephrectomy and ureterectomy, excision of the ureterocele, and reimplantation of the lower pole ureter. Upper pole heminephrectomy and ureterectomy, the decompressed ureterocele being left in the bi adder. Upper to lower uretero-ureterostomy, the decompressed ureterocele being left in the bladder.
436
SPR
5.
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The selected anatomic determined
Excision of the ureterocele and common-sheath reimpl antati on. operative procedure should be on the basis of the underlying and physiologic abnormalities as by IVP and VCUG.
Ultrasound and Computed Tomography and Perirenal Diseases in Infants Children: RelationshiptoExcretory in RenaT Cystic_Disease, Trauma Neopiasms: Berger PEI Munschauer Kuhn JP (Children’s Hospital of Buffalo, NY 14222)
of aid
Renal
Urograpy and RW, Buffalo,
47 infants and children had excretory urography, ultrasound, and computed tomographic examinations with the renal and penrenal areas as primary regions of interest. Ultrasound is an excellent screening procedure, may often be diagnostic, and may be the only imaging examination necessary. We have found this to be the case with suspected renal cystic disease and recommend ultrasound as the initial procedure. The excretory urogram may be inaccurate, as was the case in 4 of 14 patients, and is often unnecessary. Computed tomography can provide superior anatomic detail and measure tissue densities. This makes it the imaging procedure which best demonstrates the extent of renal injury (often grossly underestimated by excretory urography) and best delineates the character and extent of solid renal and penirenal neoplasms. For children with solid tumors of the retropenitoneal area, we feel CT is not only justified (after screening by ultrasound) but is the definitive examination. Excretory urography is often unnecessary in these conditions.
Corticomedullary Differentiation The Most Informative Phase of Intravenous yelography: Yousefzadeh DK, Lupetin A, Jackson JH, Jr. (Univ. of Iowa Hospitals and Clinics, Iowa City, IA 52242) Since renal cortical blood flow is considerably greater than that of either the penirenal structures or medulla, the maximal differentiation of the cortex from its inner and outer neighbors is achieved 4 or 5 seconds after completion of rapid injection of contrast medium through one or two upper extremity veins. The high-quality image during this transient period of corticomedullary differentiation often resembles an excellent coronal cut of the kidney cortex, despite such well known obstacles as bowel gas and feces. The image deteriorates as the time of the first exposure approaches the total body opacification phase and thereafter. The clarity of the renal outline and its architecture diminishes because of fading of kidney density and corticomedullary differentiation. The vascular anatomy, often surprisingly well shown by this technique, is an added bonus. Sometimes arteniography is obviated. Even tumor vessels may be seen.
ABSTRACTS
AJR:133,
September
1979
Two to four images at intervals of 1 or seconds can be obtained while a 14 x 17 cassette parked in a Bucky tray is manually advanced cephalad once or twice or three times, over 1/2 or 1/3 or 1/4 of its length, until it is fully exposed. This technique has made tomography unnecessary. Cleansing enemas and carbonated beverages are avoided. The dose of the contrast medium and the radiation dose need not exceed those of conventional methods.
:
Routine Lateral Chest 1eonata1 IntensiveCare Vu P, Smith WL, Smith Schreiner RL (Indiana Indianapolis, IN 46202)
Radiogra h in the Unit: rankenEA, JA, Gresham EL, Univ. School of 1ledicine,
This study was designed to assess the diagnostic efficacy of the routine lateral chest film in symptomatic newborn infants. AP and cross-table lateral chest radiographs were done in 53 consecutive patients upon admission to the newborn intensive care unit. Subsequently three radiologists and two neonatologists performed blind, independent analyses of the films with and without the lateral film. A total of 530 sets of observations (53 x 5 x 2) were performed. Assessment of lung inflation and discovery of abnormalities of the heart, mediastinum, and trachea were unaffected by the use of the lateral radiograph. A correct primary diagnosis was made in 74% o all cases by the AP chests alone and in 71% by the AP-lateral series. Analysis of the AP chest alone compared to the AP-lateral series showed no difference in diagnostic accuracy. Degree of confidence in the primary diagnosis did not change when the lateral chest radiograph was added. There was no appreciable difference in the detection of complications of the primary disease. We conclude that the risks (radiation, environmental disturbance) of the routine admitting lateral chest radiograph are substantially greater than any benefits to be gained.
Patterns of Evolution of theChest Rej1ratory Distress Sndime: Todres D (Massachusetts iene’-al Harvard Medical School, Boston,
X-ray Cleveland Hospital, MA 02114)
in RH,
Since bronchopulmonary dysplasia was first described as a complication of hyaline membrane disease, much attention has been given to the “white out phase, which has generally been interpreted as an ominous development. In a series of 110 newborns admitted to our intensive care unit in a 2 1/2 year period, there were 21 children showing 22 instances of pulmonary iiwhite out, radiographically consistent with Northway’s stage II bronchopulmonary dysplasia. However, only 11 (50%) of these occurred in critically ill infants. All 11 were receiving close to 100% 02, and perhaps their iiwhite out” is explained by the resorp-
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AJR: 133, September
SPR
1979
tive atelectasis known to occur with hightension 02 administration. The other 11 children developed their “white out” as they were being weaned from the ventilator. In most of these infants, the radiograph showing the “white out” was obtained shortly after a significant decrease in artificial ventilatory pressure. In all 11 a more normally aerated chest was documented shortly after the “white out”. A similar transient, innocuous process has recently been demonstrated in adults and results from a decrease in ventilatory pressures.
Radiological Abnormalities of the_Phry,.. Pre-Vertebral Soft Tissues fn Infectious Mononucleosis: Sato Y, DunbarR’TChi1dren’s Hospital Medical Center, Cincinnati OH
Dystrophy in Children: (CTiildren’s Hospital Center, Washington, DC
437
In eight cases the radionuclide bone scans showed decreased blood flow to the involved extremity and decreased uptake of radionuclide in the bones. The other two children showed increased blood flow and juxtaarticular increase in uptake, similar to the pattern reported in adults with this syndrome. The bone scans helped in establishing the diagnosis and in excluding other causes of extremity pain. Separation of Larsen Syndrome from the ‘Arthrogryposis BaskeF: Houston CS, Shokeir MHK, Reed MH (Univ. Hospital Saskatoon, SASK S7H 0W8) and
45229)
Infectious mononucleosis may cause inflammatory swelling of the adenoids, the tonsils, or the cervical pre-vertebral soft tissues. The adenoid enlargement may be so severe as completely to occlude the nasopharynx and obstruct nasal breathing. The tonsils may be so large as to cause difficulty in breathing, and urgent tonsillectomy is occasionally required. The pre-vertebral soft tissue swelling does not cause respiratory obstruction. Review of 92 cases of infectious mononucleosis uncovered 7 children with upper airway obstruction. In each case radiographs demonstrated marked enlargement of the adenoids or tonsils or both, sometimes plus thickening of the pre-vertebral soft tissues. The larynx and trachea were not involved. Although the findings are not specific for or diagnostic of infectious mononucleosis, it is sometimes possible to suggest the diagnosis from the radiologic findings. Conversely, when a child with known infectious mononucleosis has difficulty with nasal or oral respiration or with swallowing, radiologic findings may indicate the site and severity of the obstruction. The swelling and the symptoms commonly abate with corticosteroids.
Reflex Sympathetic Majd M, FicKay DW National Medical
ABSTRACTS
20010)
The reflex sympathetic dystrophy syndrome consists of pain, hyperesthesia, vasomotor instability, and trophic skin changes in an extremity. It usually is associated with antecedent trauma. Though well known in adults, the syndrome is rarely diagnosed in children, who are often misdiagnosed as having psychiatric problems. Over the past three years we have seen ten such children. All these children had unexplained severe pain in the affected extremity. Vasomotor phenomena, such as temperature changes, were frequently overlooked at first. Radiographs were invariably normal except for osteoporosis in one case. Laboratory data were not helpful.
Arthrogryposis multiplex congenita is a heterogeneous symptom-complex. The term “arthrogryposis” does not imply etiology, does not assist in management, and does not shed light on prognosis. Larsen syndrome is one of a number of entities that have masqueraded under the heading of arthrogryposis. We report five cases. All had multiple dislocations. At least four had abnormalities of the spine. Three had equinovarus deformities, and the other two had other abnormalities of the feet. Both of the children whose wrists were examined had extra carpal bones. All five had flattening of the face, and some had orbital hypertelorism. Some had stiff joints, but others had excessively mobile joints. If our experience is at all representative, there must be hundreds of cases of Larsen syndrome, many misdiagnosed as arthrogryposis, in the files of other hospitals. Evaluation of Childhood C.y.ptogenic Hepatomegaly by Computed Toriograhy: Roy&F SA, Goldberg HI, Thaler MM (Univ of California, San Francisco, CA 94143) Computed tomography (CT) of the liver in 10 children with anicteric hepatomegaly mdicated that CT numbers often indicate the type of intrahepatic deposit responsible. CT numbers were 50-60 (old Hounsfield numbers) in 5 patients with hemochromatosis due to multiple transfusions for thalassemia, 32-40 in 3 patients with glycogen storage disease, and -5 and +5 in 2 with fatty liver due to Cushing’s disease and lipoprotein lipase deficiency respectively. CT numbers in 40 children with normal liver size and functions ranged from 12 to 32. CT numbers in 100 normal adults ranged from 16 to 34. To determine the sensitivity of CT to liver fat, fatty liver was produced in 4 dogs by surgical pancreatectomy. Each was monitored with serial CT scans and histological and quantitative triglyceride analyses of serial percutaneous liver biopsies. Changes were seen on CT images within 6 to 8 hours of pancreatectomy. The maximal decline in mean liver CT number (21 units) corresponded to an increase in liver triglyceride content from 1% to 22% of wet weight. Vigorous insulin therapy caused histological and quantitative reversal of fatty liver and return of the liver CT number to normal.
SPR
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438
ABSTRACTS
AJR:133,
September
1979
These results indicate that CT can be a sensitive, relatively specific, non-invasive tool for the diagnosis of cryptogenic hepatomegaly.
of this agent by the liver and the vastly improved imaging statistics make JYfl1Tc_ PIPIDA a desirable agent for the evaluation of biliary excretion disorders in infancy.
Lithiasis Due to Interruption hepatic Circulation of Bile (Children’s Medical Center,
The Complications of Nissen Fundoplication for Gastro&sophageiTRefTuxjn Normal and Neurolojically Impaired Patient: Radiological Di agnosi s : 0’ Connor JF, CiInl ey WR, Feins NR, Rubin RR, Cohen GR (Boston Univ. School of Medicine, Boston, MA 02118)
of the Salts: Dallas,
EnteroKirks DR TX 75235)
Bile salts are formed from cholesterol and are conjugated in the liver, excreted via the biliary system into the duodenum, reabsorbed in the ileum, stored temporarily in the hepatic bile salt pool, and re-excreted into the biliary system. We report two children in whom interruption of this enterohepatic circulation led to stone formation. In one child, ileal dysfunction due to surgical resection because of midgut volvulus led to failure of absorption of bile salts, depletion of hepatic bile salts, accumulation of cholesterol in bile, and cholesterol cholel ithiasis. In another child, ileal dysfunction due to regional enteritis led to failure of absorption of bile salts, an increase in the quantity of bile salts presented to the colon, enzymatic lysis of these salts to oxalate, absorption into the blood stream, hyperoxaluria, and an oxalate ureteral stone. Other possible mechanisms in this child include steatorrhea leading to decrease in intraluminal calcium for binding ingested oxalate, and a direct effect of unabsorbed bile salts on the colon increasing oxalate absorption. Ileal dysfunction and interruption of the enterohepatic circulation of bile salts must be added to the causes of childhood biliary and urinary lithiasis. The Evaluation Utilizing Sinatra FRThomas of Los Angeles,
of
Biliary
Atresia inInfan,y. Miller JH, DW (Children’s Hospital Los Angeles, CA 90027)
A new class of hepatobiliary imaging agents has become available; these are the Nsubstituted iminodiacetic acids. Following intravenous administration, these compounds are quickly extracted by the hepatocytes and rapidly excreted into the biliary tree. By utilizing a 99mTc label sufficient activity may be given to allow excellent gamma camera imaging. We have utilized 99mTc_labelled pisopropylacetanilido-iminodiacetic acid (PIPIDA) in the evaluation of two children suspected of having biliary atresia; in neither did the isotope appear in the gut, which correctly supported that diagnosis. In five patients we have evaluated the patency of surgically created portico-enterosmies (Kasai anastoriloses); in all five the mTc_ Sn-PIPIDA study accurately assessed patency. In comparison with the previously available agent (l3lI-Rose Bengal), the marked reduction in radiation to the liver alone should predicate the use of 9YmTc_ PIPIDA. In addition, the speed of handling
Surgical intervention for gastroesophageal reflux in infancy and childhood has become more common in the past several years. Minor complications of Nissen fundoplication include dysphagia, the “gas bloat” syndrome, inability to vomit, and “colic”. Major complications include anastomotic leaks, recurrent reflux and esophagitis, impaction of food or other forei gn body , dehi scence of the Nissen sutures, partial or complete “slipping,” injury to the spleen (occasionally requiring splenectomy), subphrenic abscess, empyema , mediasti ni ti s , pericardi ti s, fistulae, and wound infections. The role of the radiologist in most of these is evident. The authors suggest that the r.iechanism of the “slipped” Nissen is herniation of the posterior fold created by the wrapped fundus. This results in an hour-glass deformity, recurrent reflux, and occasional obstruction at the site of the deformity.
Amniography in theEarly Prenatal Detection of Thoracic, Lumbar, and SiraI MyeloiiieniWoceles: Griscm NT, Frigoletto FD, Harris GBC (Harvard Medical School, Boston, MA 02115) The family history and the maternal serum level of alpha-fetoprotein (AFP) are current screening methods for fetal myelomeningocele. Amniotic fluid AFP, ultrasonography, and amniography are the available confirmatory tests. Amniotic fluid AFP can be misleadingly positive in a variety of congenital disorders, fetal distress, contamination of the sample by fetal blood, and in normals at the high end of the standard distribution curve. Even with advanced techniques, ultrasonography may miss both a myelomeningocele sac and posterior vertebral splaying before 20 weeks. We report the amniographic examination, performed at an average of 18 weeks, of 28 fetuses. The indications were affected family members (usually an older sibling of the fetus), elevated AFP, or both. Fifteen to 30 cc. of 60% diatrizoate were injected. The end-point of the examination was a tangent view of the fetal back on a fluoroscopic spot film to show the presence or absence of a midline bulging mass outlined by the opacified amniotic fluid. Computed from phantom dosimetry, fetal irradiation was 0.66 ± .36 rads. There were 26 true negatives. Our one true positive occurred in a woman with elevated serum and amniotic fluid AFP but negative real-time ultrasonography. In the
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AJR:133, September
SPR
1979
twenty-eighth case the question of meningocele could not be answered, of polyhydramnios and dilution due duodenal atresia. We suggest that amniography be amniotic fluid AFP and ultrasonography disagree and for further certainty those tests are positive. Sonographic Evaluation HalTer JO, Kissner EG, Friedman AP (Downstate Brooklyn, NY 11203)
of the Schneidir Medical
myelobecause to used when
Pediatric N, Center,
when both
Chest:
Gray-scale sonography was performed in 28 pediatric patients with chest disease (age range: 3 days to 16 years). Sonography was very useful in the evaluation of diaphragmatic and juxtadiaphragmatic disorders such as extrapleural abscess, loculated subpulmonic effusion, ectopic kidney, ectopic spleen and diaphragmatic paralysis. In patients with an opaque hemithorax it was possible to distinguish parenchymal consolidation (inflammatory and neoplastic), pleural effusion, pleural thickening and massive cardiomegaly. Several types of anterior mediastinal and juxtacardiac masses were accurately depicted. In 5 patients it was possible to drain extrapleural abscesses following sonographic localization. Sonography is most useful for disease processes abutting the chest wall, since it is generally possible to demonstrate the interface with adjacent normal structures (heart, diaphragm, liver, air-filled lung). Although the heart can be used as a “window” into the middle and posterior mediastinum, we found sonography to be of only moderate value for masses and fluid collections in these locations. We found it impossible to distinguish a normal thymus from one involved by tumor by ultrasound. Cystic Fibrosis: Its Characteristic Appearance by Abdominal Ultrasound: Wilfl U, Reddish JM, Teele RL (Children’s Hospital Medical Center, Boston, MA 02115) We patients the ages expected, involving
reviewed the ultrasonic scans of 24 with cystic fibrosis who were between of 8 and 30 years. There was, as a high incidence of abnormalities the
liver
and
biliary
tree,
including cholelithiasis, cirrhosis, obstruction of the common bile duct, and microgallbladder. The scans also demonstrated splenomegaly and dilatation of the superior mesenteric vein in the presence of portal hypertension. Other findings were infiltration of the pancreas by fat or fibrosis with reduction of its size, enlargement of the pancreas in two cases of pancreatitis, thickening of the wall of the stomach and duodenum, and congestion of the hepatic veins and inferior vena cava. Problems in the Scintigraphic Detection of Osteomyelitis in Children: Sullivan DC, Rosen’field 45, Ogden J, Gottschalk A (NSR Yale Univ. School of Medicine, New haven, CT 06510)
ABSTRACTS
439
Bone scintigraphy with 99n’Tc-labelled compounds is recognized as a useful test for detection of acute hematogenous osteomyelitis in children. Recent studies have reported accuracies ranging from 84 to 100%. Furthermore, the text and figures in many of these papers indicate that the scintigraphic appearance of pediatric osteomyelitis is usually obvious and easily interpreted. Our cases of osteomyelitis in children are usually treated with surgical drainage, which enables us to correlate the scintiphotos with operative findings. The results of our experience differ in several respects from those reported by others. 99mTc_pyrophosphate studies in 21 children with acute hematogenous osteomyelitis were compared with radiographic, clinical, and surgical findings. Eleven scintigraphic studies revealed obvious abnormalities, 3 showed subtle abnormalities, 2 falsely suggested septic arthritis by symmetrical uptake surrounding the joint, and 5 (including 2 newborns) were normal. Two of the false negatives simultaneously had positive roentgenograms. No consistent explanation for the lack of positive isotope findings was found. We conclude that pediatric osteomyelitis represents a spectrum of scintigraphic appearances; interpretation is often difficult. Detection of Neonatal Intracranial Hemorrhage: A Comparison of Twenty Patients with. Computed Tomography and Uftrasou1: ‘Riithick C, Johnson M, Schroeder M, Guggenheim M (Denver General Hospital and Univ. of Colorado Medical Center, Denver, CO 80204) Neonatal intracerebral hemorrhage is now one of the primary factors in the morbidity and mortality of premature infants. Computed tomographic scanning has become the definitive method of diagnosis of this entity. A comparison of ultrasound to computed tomographic scanning was made in 19 premature infants to determine the feasibility and accuracy of diagnosing hemorrhage with ultrasound and the agreement on hemorrhage site and ventricular size between ultrasound and computed tomography. The ratio of ventricular size to hemispheric size can be obtained with either method. In most of our cases, the ventricular size was lower by computerized tomographic scanning than by ultrasound, perhaps because of computer averaging of the data, although differences were small. Intraventricular hemorrhages can be seen by either method. However, intracerebral hemorrhage and subarachnoid hemorrhage can be diagnosed reliably only by computed tomography. In our opinion, the initial diagnosis of the site of the bleed must be done with computed tomographic scanning. The followup evaluation can be done using the latest ultrasound equipment; this can show the most common complications, hydrocephalus and porencephaly. This approach computed tomography initially, followed by ultrasound
-
440
SPA
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is clearly invasive lowering
the most cost-effective, system, and results in a of the radiation dose to
ABSTRACTS
nonsignificant the infant.
Abdominal and Hepatic Uptake of 99mTc_ yrophosphate fn KeonaIal NecrotTzT#{241}9 Enterocolitis (NIC): Caride VJ, Ablow RC, Touloukian RJ, Matthews T, Lange RC (Yale Univ. School of Medicine, New Haven, CT 06510) 99mTc been
pyrophosphate
(99mTcpYp)
has
shown to concentrate in infarcted tissues. Eleven neonates with the clinical suspicion of NEC were studied with this agent. Also included in this study were two newborns with osteomyelitis and one newborn with myocarditis. One to four scintigrams were performed during the course of the infants’ disease. The scans were evaluated for abdominal uptake (localized or diffuse) or liver uptake and were correlated with serial abdominal x-rays and clinical factors.
AJR:133,
September
1979
Of the eleven babies with clinical suspicion of NEC, nine had abdominal uptake and seven had liver uptake, though only four had definite intramural air by radiography. In the two babies with osteomyelitis, the abdominal scintigrams were normal. The neonate with myocarditis had liver uptake and questionable abdominal uptake, for unknown reasons. In infants with sequential scans, there was a correlation between the return to normal of the clinical and radiographic signs and the scintigraphic findings. Although total or diffuse abdominal uptake of 93mTcpYp can be explained on the basis of gut or peritoneal involvement, there is no satisfactory explanation for the hepatic uptake. The quality of the radio-pharmaceutica was checked; more than 90% of the 9r.ITc activity was ggmTcpYp, ruling out the presence of appreciable quantities of colloid. The results suggest that abnormal abdominal or liver uptake of 9YmTcPYP may prove valuable as an index of continuing or resolving NEC.
