Peds

Peds Outlines

  • Neuro

    • Germinal matrix hemorrhage

    • Periventricular leukomalacia

    • Congenital

      • Dorsal induction

        • Chiari

          • Type I

            • Tonsillar herniation >5 mm.

            • Spinal nerve roots point superiorly.

          • Type II

            • Cerebellar tonsils, vermis, fourth ventricle and brain stem are herniated through the foramen magnum

            • Hydrocephalus

            • Associated with (CT MiFC)

              • Colpocephaly

              • Tectal beaking

              • Large massa intermedia

              • Fenestrated falx

              • Cervicomedullary kink

              • Corpus callosum abnormalities

              • Tethered cord

              • Lumbosacral myelocele or meningomyelocele

          • Type III

            • Chiari II with herniation through occipital or high cervical encephalocele

      • Ventral induction

        • Holoprosencephaly

          • Lobar

            • Formation of the interhemispheric fissure is incomplete

            • White matter fibers can be seen anterior to corpus callosum

            • Failure of clevage of cerebral hemispheres frontally

          • Semilobar

            • Partial development of the interhemispheric fissure

            • Partial fusion of the thalami

            • Temporal horns may be formed

            • Single ventricle anteriorly

            • Falx may present posteriorly

          • Alobar

            • Monoventricle

            • Fused thalami

            • No falx

            • No corpus callosum

            • DiffDx of alobar holoprosencaphaly

              • Hydranencephaly => no cortical mantle is discernible around the dilated CSF space

              • Maximal hydrocephalus => midline structures are present

          • Septooptic dysplasia

            • Septum pellucidum is partially or completely absent

            • Small optic nerves and chiasm

        • Dandy-Walker

          • Proposed etiology => obstruction of foramen of Magendie and Lushka

          • Vermian hypoplasia or aplasia

          • Large cystic structure in the posterior fossa, which communicated with 4th vetricle

          • Hydrocephalus is common

          • Associated with

            • Holoprosencephaly

            • Agenesis of corpus callosum

            • Polymicrogyria

            • Heterotopias

          • Torcular-Lambdoid inversion

            • Elevation of torcular above the lambdoid suture

          • Dandy-Walker complex

            • Posterior fossa enlarged

          • Dandy-Walker variant

            • Posterior fossa is normal

            • Hypoplasia of cerebellar vermis

          • Presence of falx cerebelli rules Dandy-Walker malformation

          • Differential dx

            • Giant cisterna magna (no mass effect)

            • Arachnoid cyst (mass effect)

        • Dysgenesis of corpus callosum

          • Colpocephaly

          • Squared lateral ventricles

          • Probst bundles

          • High-riding third ventricle

          • Associated with lipomas and arachnoid cysts

      • Migration anomalies

        • Gray matter heterotopias

          • Nodular

          • Band heterotopia

        • Schizencephaly

          • Cleft with grey matter lining coursing from ventricular ependyma to pia

            • Closed-lipped

            • Open-lipped

        • Lissencephaly

          • Incomplete => pachygyria

          • Complete => agyria

          • Types

            • Type 1

            • Type 2

            • Type 3

            • Type 4 => congenital

          • Lissencephaly is a migrational disorder – cortex is thick (in normal premature brain – cortex is thin)

          • Walker-Warburg syndrome

            • Lissencephaly with dysmorphic heterotopic gray matter

            • Optic disk anomalies

            • Hydrocephalus

            • Posterior fossa malformations

        • Polymicrogyria

      • Injury of formed structures

        • Hydranencephaly

          • Falx present

          • Bilateral ICA occlusion

          • DiffDx

            • Maximal hydrocephalus

        • Porencephaly

          • CSF cyst

      • Cysts

        • Aracnoid cysts

          • Follow CSF signal

            • Maybe slightly higher on PD, FLAIR, and DWI due to stasis of fluid and pulsation effects. Mass effect on adjacent brain tissue is present. Bone remodelling may be present.

          • Differential diagnosis:

            • Subdral hygroma – crescentric in shape, mass effect on adjacent brain tissue, T1W and FLAIR signal is different from CSF due to usual presence of blood products from leptomeningeal tears

            • Normal subarachnoid space due to adjacent encephalomalacia – no mass effect present, cerebral veins can be seen crossing the enlarged subarachnoid space.

            • Epidermoid – bright on FLAIR and DWI

        • Rathke cleft cysts

          • Remnants of neuroectoderm that ascends from oral cavity to form anterior pituitary and pars intermedia

          • Classic location of Rathke cleft cyst is between anterior and posterior pituitary.

        • Meningoceles and meningoencephaloceles

        • Neuroepithelial cysts

          • Arise within the ependyma

        • Leptomeningeal cyst (growing fracture)

          • Leakage of CSF from pia-arachnoid

          • Protrusion of leptomeninges through dural tear

          • Formation of encapsulated cyst

      • Cortical dysplasia

      • Joubert syndrome

        • Parallel enlarged horizontally oriented superior cerebellar peduncles => molar tooth sign

      • Klippel-Feil syndrome

        • C2-C3 fusion

        • Short clivus

        • Odontoid or C1 abnormalities

      • Neurocutaneous syndromes

        • NF1

        • NF2

        • TS

        • Sturge-Weber

          • Low flow vascular malformation along distribution of trigeminal nerve extracraniallu and intracranially

          • Altered flow results in chronic ischemic injury

    • Masses

      • Pediatric supratentorial neoplasms

        • Short list (GPEC)

          • Gliomas

          • PNET

          • Ependymoma

          • Choroid plexus tumors

        • Long list

          • Pleomorphic xanthoastrocytoma

          • Embryonal

            • PNET

            • Medulloepithelioma

            • Ependymoblastoma

          • Neuronal

            • Ganglioglioma

            • Gangiocytoma

            • Dysembyonic neuroepithelial tumor (DNET)

      • Pediatric infratentorial neoplasms (AMEC)

        • Astrocytomas

          • Juvenile pilocytic astrocytomas

            • Cystic, some have mural nodule (similar to adult hemagioblastoma)

          • Brainstem astrocytomas

        • Medulloblastoma (PNET of the posterior fossa)

          • Arises from roof of 4th ventricle

        • Ependymomas

          • Arises from floor of 4th ventricle

          • Children => 4th ventricle, Adults => hemispheres

        • Choroid plexus papillomas

      • Parasellar masses (GCG ET)

        • Gliomas (optic glioma and hypothallamic glioma)

        • Craniopharyngioma

        • Germ cell tumors (present with diabetes insipidus)

        • EG (presents with diabetes insipidus)

          • Lytic skull lesion with no sclerosis at the margins

          • Thickening of pituitary infundibulum

          • Vertebrae plana

          • Floating tooth sign

        • Tuber cinereum hamartoma

    • Skull

      • Dolichocephaly

        • Sagittal suture synostosis

      • Trigonocephaly

        • Metopic suture synostosis

      • Cloverleaf skull

        • Synostosis of all sutures

      • Lacunar (luckenschnadel) skull

        • Associated with myelomengocele

    • C-spine

        • Normal variants Radiographics 2003

          • Anterior dental interval =/< 5mm

          • Pseudo Jefferson Fx =/< 6mm

          • Pseudosubluxation C2-C3, C3-C4

            • Posterior cervical line should be maintained

          • Anterior vertebral body wedging

    • Face

      • Nasal cavity

        • Neoplasms

          • Juvenile angiofibroma => occurs in adolescent boys

    • Neck

      • Inflammatory

        • Adenoids become pathologic when they encroach on the nasopharyngeal airway

        • Retropharyngeal abcess

          • The width of prevertebral soft tissues should not exceed 1/2 of the vertebral bodywidth in the upper neck from C1 to C4-C5 in children less than 3 years of age

        • Acute epiglottitis

        • AIDS

          • Cervical nodal enlargement with cystic parotid lesions

      • Masses

        • Cystic

          • Thyroglossal duct cyst

          • Branchial cleft cyst => usually in the anterior cervical traingle, at the angle of the jaw

          • Lymphangiomas / Cystic hygromas (posterior cervical triangle)

          • Ranula => epithelial retention cyst

          • Cervical thymic cysts

        • Other

          • Fibromatosis colli

          • Hemangiomas

          • Dermoid/Teratoma

          • Lingual thyroid

          • Rhabdomyosarcoma => most common malignant neoplasm

          • Hodgkin’s lymphoma

          • Neuroblastoma

      • Airway

          • Choanal atresia

          • Acute epiglottitis

          • Viral croup

          • Membranous croup (Staph. aureus)

          • Subglottic hemangioma

          • Laryngeal papilloma

          • Tracheal granuloma (ETT)

          • Laryngomalacia

          • Hereditary angioneurotic edema (C1 esterase deficiency)

      • Thyroid

      • Parathyroid

  • Chest

    • Mediastinum

      • Aortic arch anomalies

        • Left arch with aberrant right SC artery (most common)

        • Right arch

          • Right arch with aberrant left SC artery (complete ring around trachea and esophagus)

            • Complete ring

            • Impression on posterior wall of esophagus and on right lateral wall of esophagus

          • Right arch with mirror image branching

            • Associated with cardiac anomalies

          • Double aortic arch

            • Posterior compression of esophagus on lateral view (bilateral compression on the frontal view)

      • Pulmonary arteries anomalies

        • Left pulmonary artery sling

          • Arises from the right pulmonary artery

      • Venous

        • Persistent left SVC

        • Azygoud continuation of IVC

      • TAPVR/PAPVR

      • Aortic aneurysm

        • Marfans

        • Ehlers-Danlos

        • Takayasu

        • Kawasaki

      • Aortic dissection

        • Marfan

      • Cardiac

        • Increased pulmonary blood flow, acyanotic (Left-to Right Shunts)

          • LAE

            • VSD

            • PDA

          • No LAE

            • ASD – Right atrial enlargement

            • PAPVR

            • AV canal

          • Eisenmenger (large central pulmonary arteries and decreased size of peripheral vessels)

        • Decreased pulmonary blood flow, cyanotic, no cardiomegaly

          • ToF

          • Pulmonary stenosis

          • Tricuspid atresia

          • Pulmonic atresia

        • Decreased pulmonary blood flow, cyanotic, cardiomegaly

          • Ebstein anomaly

          • Pulmonary stenosis (critical)

          • Tricuspid atresia

          • Pulmonic atresia

        • Increased pulmonary blood flow, cyanosis

          • TGA

            • Egg on a string (D-transposition)

          • TAPVR

            • Snowman sign

          • Truncus arteriosus

            • Right sided aortic arch

            • Cardiomegaly

            • Increased pulmonary blood flow

            • Waterfall sign

          • Tricuspid atresia

          • Single ventricle

          • DORV

        • Normal pulmonary blood flow, acyanotic

          • Coarctation of aorta

            • Reverse "3" sign

          • AS

          • Valvular pulmonic stenosis

        • Pulmonary venous hypertension

          • Hypoplastic left heart syndrome

          • Interrupted aortic arch

          • Anomalous coronary arteries

          • Cardiomyopathy

          • Kawasaki disease

        • CHF

          • Vein of Galen malformation

          • Hemangioendothelioma

          • Other vascular malformations

    • Developmental lung anomalies

      • Primary lung anomalies

        • Lung agenesis

        • Lobar underdevelopment

          • Intrathoracic factors => diaphragmatic hernia, extralobar sequestration

          • Extrathoracic factors => oligohydramnios, arthrogryposis

          • Scimitar(venolobar) syndrome => unique form of lobar agenesis or aplasia associated with other anomalies

      • Secondary anomalies

        • Congenital diaphragamtic hernia

        • Bronchiolitis obliterans (Swyer-James or Macleod syndrome) can cause lung hypoplasia

          • Hyperlucent lung

          • Expiration films show air trapping in the hyperlucent region

          • Lung scintigraphy shows delayed wash-in and wash-out due to air trapping and decreased perfusion

      • Masses

        • Sequestration

          • Intralobar => most common

            • Contained within the visceral pleura of the lung

            • Presents as PNA

            • Single large artery from infradiaphragmatic aorta enters lung via pulmonary ligament

            • Venous drainage via pulmonary veins

          • Extralobar => associated with CCAM

            • Enclosed by its own visceral pleural envelope

            • Usually asymptomatic

            • Receives several branches from systemic and occasionally pulmonary arteries

            • Venous drainage via systemic veins

          • Pathology: cystic and bronchiectatic lung

          • Radiology: solid or multicystic air collection

        • Congenital cystic adenomatoid malformation

          • Type I => Single/multiple cysts > 2cm

          • Type II => Smaller cysts < 2cm mixed with solid components

          • Type III => Solitary solid masses

        • Congenital lobar emphysema

          • Initially dense due to fluid in the air spaces

          • Hyperinflated lucent lobe

        • Bronchogenic cysts

        • Neurenteric cysts

      • Pulmonary AVM

    • Neonatal

      • Hyaline membrane disease (RDS)

        • Premature infants born prior to 37 weeks

        • If CXR is normal at 6 hours, RDS is unlikely

        • Hypoaeration and symmetric reticulogranular opacities, no pleural effusions

        • Complications

          • Barotrauma => pulmonary interstitial emphysema

          • Left to right shunting across patent PDA => pulmonary edema

          • Bronchopulmonary dysplasia

      • Retained fetal lung liquid (transient tachypnea of newborn)

        • Usually seen after c-section

        • Peak symptoms are at 24-36 hours

        • Reticular opacities

        • DiffDx: pulmonary lymphangiectasia, TAPVR with obstruction, streptocococcal PNA, mild HMD (need serial radiographs for differentiation).

      • Meconium aspiration

        • Postmature neonates

        • Chemical pneumonitis

        • Hyperinflation and bilateral interstitial and airway opacities. Pneumothorax and pneumomediastinum may result from alveolar rupture.

      • Pulmonary lymphangiectasia

        • Overaeration, coarse nodular or reticular opacities, Kerley B lines, pleural effusions

      • Neonatal pneumonia (prolnged rupture of membranes is a risk factor)

        • GBS

          • Reticulogranular opacities

          • Pleural effusions

        • Chlamydia (2 weeks to 3 months of age)

          • Associated with conjunctivitis

          • Hyperinflation and asymmetric interstitial and alveolar opacities

    • Bronchiectasis

      • Cystic fibrosis => bronchiectatic cavities predominantly in upper lobes.

      • Kartagener syndrome => immotile cilia (sinusitis, OM, bronchiectasis, deafness and infertility), thoracic and cardiac situs inversus

      • Localized from post-infectious causes

    • Unilateral hyperlucency

      • Swyer-James syndrome

        • Small hyperlucent lung

      • Foreign body

      • PTX

      • Congenital lobar emphysema

      • Compensatory hyperinflation

    • PNA

      • Round PNA usually related to strep. pneumoniae

      • Parenchymal cavitation => staph. aureus

      • TB

      • Histoplasmosis

    • Aspergillus

      • Aspergilloma

      • ABPA

        • Bronchiectasis with impacted mucus

      • Invasive aspergillosis

        • Nodular opacities which undergo cavitation

    • Diffuse lung disease

      • Central airways

        • CF

        • Dyskenetic cilia syndrome

          • Kartegener syndrome

            • Situs inversus, bronchiectasis and sinusitis (SBS)

      • Small airway disease

        • Bronchiolitis obliterans (tree-in-bud, mosaic pattern, centrilobular nodules)

        • Swyer-James (Macleod) syndrome

      • Interstitial disease

        • BPD (bronchiectasis usually absent)

        • IPF

        • Cysts

          • LCH (nodules then cysts)

          • TS

      • Air space attenuation

        • Alveolar proteinosis ("crazy paving")

        • Hemosiderosis

        • Pulmonary edema

      • Emphysema

        • Alpha-1-antitrypsin deficiency

    • Bones (NELOL OMOF)

      • Neuroblastoma

      • Ewing

      • LCH

      • Osteosarcoma

      • Leukemia

      • Osteomyelitis

      • Mesenchymal hamartoma

      • Osteochondroma

      • Fibrous dysplasia

    • Soft tissues (LHL REP)

      • Lymphangioma (fluid filled)

      • Hemangioma (phleboliths, flow)

      • Lipoma

      • Rhabdomyosarcoma

      • Ewing (PNET)

  • GI

    • Esophageal atresia/TEF

      • VACTERL

    • Hypertrophic pyloric stenosis

      • 3.14 => wall thickness – 3mm, length of pyloric channel – 14 mm

    • Obstruction in infancy

      • High (MAD3)

        • Malrotation/midgut volvulus

          • Duodenal-jejunal junction should be at the same height as duodenal bulb and at least over left vertebral pedicle

          • On US, SMA and SMV relationship may be reversed

        • Annular pancreas

        • Duodenal stenosis

        • Duodenal web

        • Duodenal atresia

      • Low (MIMAH)

        • Meconium plug (small left colon syndrome)

          • Infants born of diabetic mothers

        • Ileal atresia

        • Meconium ileus (CF)

        • Anal atresia

        • Hirschprung disease

    • Obstruction in children (AAIIMM)

      • Adhesions

      • Appendicitis

      • Intussusception

        • 3 mos to 1 yr (3yrs)

        • Currant jelly stools

        • Crescentic fat within the intussesceptum => mesentery drawn into the intussesceptum

        • Rates of reduction with air or liquid contrast are not statistically different

      • Incarcerated inguinal hernia

      • Malrotation with volvulus

      • Meckel diverticulum

        • Tc-99m pertechnetate localizes to gastric tissue

          • May be false negative if Meckel’s diverticulum little or no gastric tissue

        • Obstruction results from inversion of diverticulum

        • Calcified stones or lamellated pattern in the lower right quadrant

    • Appendicitis

      • On US: hyperemic, non-compressible appendix, 6mm

    • NEC

      • Unchanging bowel gas pattern over several films

      • Pneumatosis

    • Duplication cysts

      • Round cysts with bowel wall signature on US, ususally do not communicate with lumen

      • Tubular duplications are less common, but may communicate with lumen

    • Mesentery

      • Mesenteric adenitis

    • CF

      • Meconeum ileus

      • Meconium ileus equivalent

      • Pseudomembranous colitis

      • Colonic thickening or stricture from pancreatic enzyme replacement

      • Gallstones

      • Pancreatic atrophy

    • Immunocompromised patient

      • Pseudomembrabous colitis

      • Neutropenic colitis (typhlitis)

      • Graft-Versus-Host disease

      • Mucositis

      • Lymphoprliferative disorders

        • Proliferation of EBV infected cells

  • Liver

    • Jaundice

      • Neonatal hepatitis

      • Biliary atresia

    • Hepatic masses – age < 5 years (HHMM)

      • Hepatoblastoma

        • Infants to 5 years old (most occurences prior to age 2 years)

        • Well defined lesions that displace rather than invade structures

      • Hemangioendothelioma

      • Mesenchymal hamartoma

      • Mestastatic disease (neuroblastoma and Wilms)

    • Hepatic masses – age > 5 years (HHELM)

      • HCC

        • Fibrolamellar HCC

      • Hepatic adenoma

      • Embryonal sarcoma

      • Lymphoma

      • Metastatic disease

  • GU

    • Adrenals

      • Neuroblastoma

      • Adrenal hemorrhage

    • Kidneys

      • UPJ obstruction

        • Intrinsic narrowing

        • Compression by anolmalous vessel

      • Cystic kidney disease

        • MCDK

          • Severe obstruction during fetal development

          • Cysts that do not communicate

          • Non-functioning kidney

        • ARPCKD

          • Large kidneys

          • Juvenile polycystic kidney disease

        • ADPCKD

      • Tumors

        • Wilms tumor (nephroblastoma)

          • Calcifications uncommon (calcifications are common in neuroblastoma)

          • Displaces blood vessels (neuroblastoma engulfs blood vessels)

        • Nephroblastomatosis

          • Persistent nephrogenic rests

        • Multilocular cystic nephroma

        • Mesoblastic nephroma

          • Usually encountered during the first few months of life

    • Ureter

      • Primary megaureter

        • Aperistaltic distal ureter

      • Ureterocele

      • VUR

        • Grade III – blunting of calyces

    • Bladder

      • Prune-Belly syndrome

        • Hypoplasia of abdominal musculature

        • Cryptorchidism

        • GU tract abnormalities

    • Pelvic rhabdomyosarcoma

    • Urethra

      • PUV

    • Hydrometrocolpos

  • MSK

    • CRITOE => Sequence of appearance of ossification centers (1,3,5,7,9,11 years)

  • Metabolic

    • Hypoparathyroidism and pseudohypoparathyroidism => basal ganglia calcifications.

  • Lines

    • Umbilical vein =>

      • ductus venosus => IVC (T8-T9)

      • portal vein  =>  hepatic sinusoids =>  hepatic  veins =>  IVC

    • Umbilical artery => interal iliac artery => common iliac artery => aorta (T6-T9)