SUMPh N. Testemitanu Radiology and Medical imaging department PEDIATRIC IMAGING. M. Crivceanschii, assistant professor

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1 SUMPh N. Testemitanu Radiology and Medical imaging department PEDIATRIC IMAGING M. Crivceanschii, assistant professor

2 GOALS AND OBJECTIVES to be aware of the role of modern diagnostic imaging modalities and use proper sequences in pediatric imaging to be familiar with radiological findings in common pediatric pathologic conditions tips and tricks in pediatric imaging that every student should now

3 IMAGING MODALITIES

4 IMAGING MODALITIES Conventional Radiography Computed Tomography Magnetic Resonance Imaging Ultrasonography Angiography Scintigraphy, Positron Emission Tomography, PET/CT

5 COMMON PEDIATRIC CONDITIONS 1. Newborn respiratory distress 2. Childhood lung disease 3. Soft tissues of the neck 4. Other diseases

6 NEWBORN RESPIRATORY DISTRESS 1. Transient tachypnea of the newborn 2. Neonatal respiratory distress syndrome (hyaline membrane disease) 3. Meconium aspiration syndrome 4. Bronchopulmonary dysplasia

7 TRANSIENT TACHYPNEA OF THE NEWBORN Most common cause of respiratory distress in the newborn. Result of delay in the resorption of fetal lung fluid. Clinically: immediate onset of tachypnea, typically improve over several hours with oxygen and supportive therapy and completely recover by 48 hours. Imaging findings: hyperinflation, streaky perihilar linear densities, fluid in the fissures and/or laminar pleural effusions.

8 TRANSIENT TACHYPNEA OF THE NEWBORN All images Learning Radiology. Recognizing the basics. 3 rd edition.

9 RESPIRATORY DISTRESS SYNDROME OF THE NEWBORN (HYALINE MEMBRANE DISEASE) Is a disease of premature infants The major cause of this disorder is surfactant deficiency. Clinically: cyanosis, grunting, nasal flaring, intercostal and subcostal retractions, and tachypnea. Imaging findings: diffuse ground-glass or finely granular appearance to the lungs in a bilateral and symmetric distribution; air bronchograms; hypoaeration; air leak - a complication of positive pressure ventilation.

10 RESPIRATORY DISTRESS SYNDROME OF THE NEWBORN All images Learning Radiology. Recognizing the basics. 3 rd edition.

11 MECONIUM ASPIRATION SYNDROME Is the most common cause of neonatal respiratory distress in postmature infants. Clinically: severe respiratory distress almost immediately; tachypnea, hypoxia, and hypercapnia. Imaging findings: The lungs are hyperinflated with diffuse ropey densities (similar in appearance, but not in timing, to bronchopulmonary dysplasia). There may be patchy areas of atelectasis and emphysema from air trapping. Spontaneous pneumothorax and pneumomediastinum occur in 25%.There may be an associated pneumonia.

12 MECONIUM ASPIRATION SYNDROME All images Learning Radiology. Recognizing the basics. 3 rd edition.

13 MECONIUM ASPIRATION SYNDROME All images Learning Radiology. Recognizing the basics. 3 rd edition.

14 BRONCHOPULMONARY DYSPLASIA Is a consequence of early, acute lung disease, frequently respiratory distress syndrome. Is defined as oxygen dependence at 28 days of life to maintain arterial oxygen tensions >50 mm Hg accompanied by abnormal chest radiographs. Clinically: oxygen dependence, hypercapnia, and a compensatory metabolic alkalosis. Imaging findings: hyperaerated lungs, coarse, irregular, ropelike, linear densities, representing atelectasis or, later, fibrosis; air trapping.

15 BRONCHOPULMONARY DYSPLASIA All images Learning Radiology. Recognizing the basics. 3 rd edition.

16 CHILDHOOD LUNG DISEASE 1. Reactive airways disease/bronchiolitis 2. Asthma 3. Pneumonia

17 REACTIVE AIRWAYS DISEASE/BRONCHIOLITIS Group of diseases in the pediatric population featuring wheezing, shortness of breath, and coughing. Unlike asthma, which is chronic, reactive airways disease is usually transient, although it can progress over time to asthma. Clinically: tachypnea, retractions, cough, fever, and rhinorrhea. Imaging findings: peribronchial thickening, hyperinflation of the lungs, atelectasis from mucus plugging may be present.

18 REACTIVE AIRWAYS DISEASE/BRONCHIOLITIS All images Learning Radiology. Recognizing the basics. 3 rd edition.

19 ASTHMA Asthma is a clinical, not a radiologic, diagnosis. Complications include atelectasis secondary to plugging by mucus, pneumothorax, and pneumomediastinum. During or after an acute attack, the lungs may be overaerated with flattening of the diaphragm. There may be peribronchial thickening.

20 ASTHMA All images Learning Radiology. Recognizing the basics. 3 rd edition.

21 PNEUMONIA Age is a determining factor in both the causes and clinical presentation of childhood pneumonia. Clinically: fever, chills, tachypnea, cough, pleuritic chest pain, and shortness of breath. Imaging findings: - Bacterial pneumonia - characteristically produces lobar consolidation, or around pneumonia, with pleural effusion in 10% to 30% of cases. - Viral pneumonia - characteristically shows interstitial infiltrates or patchy areas of consolidation suggestive of bronchopneumonia.

22 PNEUMONIA All images Learning Radiology. Recognizing the basics. 3 rd edition.

23 SOFT TISSUES OF THE NECK 1. Enlarged tonsils and adenoids 2. Epiglottitis 3. Croup (laryngotracheobronchitis) 4. Ingested foreign bodies

24 ENLARGED TONSILS AND ADENOIDS Newborns do not have visible adenoids. Not visible radiographically until 3 to 6 months. Clinically: nasal congestion, mouthbreathing, chronic or recurrent otitis media as a result of their proximity to the Eustachian tubes, painful swallowing, and sleep apnea. Imaging findings: look for marked narrowing or obliteration of the nasopharyngeal airway.

25 ENLARGED TONSILS AND ADENOIDS All images Learning Radiology. Recognizing the basics. 3 rd edition.

26 EPIGLOTTITIS Life-threatening medical emergency. Peak incidence from about 3 to 6 years of age. Clinically: resembles croup, classical triad of epiglottitis is drooling, severe dysphagia, and respiratory distress with inspiratory stridor. Imaging findings: enlargement of the epiglottis, thickening of the aryepiglottic folds, narrowing of the subglottic portion of the trachea.

27 EPIGLOTTITIS E All images Learning Radiology. Recognizing the basics. 3 rd edition.

28 CROUP (LARYNGOTRACHEOBRONCHITIS) It typically occurs from age 6 months to 3 years. It frequently follows a common cold. Clinically: harsh cough described as barking or brassy, associated with hoarseness, inspiratory stridor, lowgrade fever, and respiratory distress. Imaging findings: distension of the hypopharynx, distension of the laryngeal ventricle, and haziness and/or narrowing of the subglottic trachea.

29 CROUP (LARYNGOTRACHEOBRONCHITIS) E All images Learning Radiology. Recognizing the basics. 3 rd edition.

30 INGESTED FOREIGN BODIES Majority occur between 6 months and 6 years. 80% pass spontaneously. Often, they impact just below the cricopharyngeus at the level of C5-C6 (70%) at the aortic arch (20%), or at the level of the esophagogastric junction (10%). Major complications of ingested foreign bodies are perforation, obstruction, or stricture formation. Clinically: dysphagia and odynophagia. Imaging findings: depend on whether the foreign body is opaque or not.

31 INGESTED FOREIGN BODIES All images Learning Radiology. Recognizing the basics. 3 rd edition.

32 OTHER DISEASES 1. Cardiomegaly in infants 2. Salter-Harris epiphyseal plate fractures 3. Child abuse 4. Necrotizing enterocolitis 5. Esophageal atresia with/without tracheoesophageal fistula

33 CARDIOMEGALY IN INFANTS Cardiothoracic ratio may reach up to 65% in infants. Any assessment of cardiac enlargement in an infant should take into account other factors such as the appearance of the pulmonary vasculature, and any associated (e.g., a murmur, tachycardia, or cyanosis). Thymus gland may overlap portions of the heart and sometimes mimic cardiomegaly.

34 CARDIOMEGALY IN INFANTS All images Learning Radiology. Recognizing the basics. 3 rd edition.

35 SALTER-HARRIS EPIPHYSEAL PLATE FRACTURES In growing bone, the hypertrophic zone in the growth plate (epiphyseal plate or physis) is most vulnerable to injury. Account for as many as 30% of childhood fractures. The Salter-Harris classification of epiphyseal plate injuries is a commonly used method of describing such injuries that helps identify the type of treatment required and predicts the likelihood of complications based on the type of fracture.

36 SALTER-HARRIS EPIPHYSEAL PLATE FRACTURES Radiologyassistant.nl image

37 SALTER-HARRIS EPIPHYSEAL PLATE FRACTURES TYPE I All images Learning Radiology. Recognizing the basics. 3 rd edition.

38 SALTER-HARRIS EPIPHYSEAL PLATE FRACTURES TYPE II All images Learning Radiology. Recognizing the basics. 3 rd edition.

39 SALTER-HARRIS EPIPHYSEAL PLATE FRACTURES TYPE III All images Learning Radiology. Recognizing the basics. 3 rd edition.

40 SALTER-HARRIS EPIPHYSEAL PLATE FRACTURES TYPE IV All images Learning Radiology. Recognizing the basics. 3 rd edition.

41 SALTER-HARRIS EPIPHYSEAL PLATE FRACTURES TYPE V All images Learning Radiology. Recognizing the basics. 3 rd edition.

42 CHILD ABUSE There are several fracture sites and characteristics that should raise the suspicion for child abuse: 1. metaphyseal corner fracturesparallel the metaphysis and can have a buckethandle appearance 2. rib fractures - especially multiple fractures, and/or fractures of the posterior ribs 3. head injuries - subdural and subarachnoid hemorrhage and cerebral contusions; skull fractures

43 CHILD ABUSE All images Learning Radiology. Recognizing the basics. 3 rd edition.

44 CHILD ABUSE All images Learning Radiology. Recognizing the basics. 3 rd edition.

45 NECROTIZING ENTEROCOLITIS Most common gastrointestinal medical and/or surgical emergency occurring in neonates. More common in premature infants but can also be seen in term babies. Clinical findings may be subtle and can include feeding intolerance, delayed gastric emptying, abdominal distention, and/or tenderness, and decreased bowel sounds. Imaging findings - most commonly affects the terminal ileum, distended loops of bowel, pneumatosis intestinalis, abdominal free air.

46 NORMAL INFANT ABDOMEN All images Learning Radiology. Recognizing the basics. 3 rd edition.

47 NECROTIZING ENTEROCOLITIS All images Learning Radiology. Recognizing the basics. 3 rd edition.

48 ESOPHAGEAL ATRESIA WITH/WITHOUT TRACHEOESOPHAGEAL FISTULA The most common form is a blind-ending esophagus (esophageal atresia), with a fistulous connection between the trachea and the distal esophageal remnant. Clinical findings choking, drooling, difficulty handling secretions, regurgitation, aspiration, and respiratory distress. Imaging findings - with esophageal atresia and no fistula - no air enters the GI tract, so the abdomen is airless. With a distal fistula - gas in the bowel that has entered via the trachea.

49 ESOPHAGEAL ATRESIA WITH TRACHEOESOPHAGEAL FISTULA All images Learning Radiology. Recognizing the basics. 3 rd edition.

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