Pediatric Imaging: Case Review Series, Second Edition

405 Pages·2010·52.2 MB·English

by  Thierry A. G. M. Huisman MD

C A S E R E V I E W
Pediatric Imaging
SeriesEditor
DavidM.Yousem,MD,MBA
ProfessorofRadiology
DirectorofNeuroradiology
TheRussellH.MorganDepartmentofRadiologyandRadiologicalScience
JohnsHopkinsMedicalInstitutions
Baltimore,Maryland
OtherVolumesintheCASEREVIEWSeries
BrainImaging
BreastImaging
CardiacImaging
EmergencyRadiology
GastrointestinalImaging
GeneralandVascularUltrasound
GenitourinaryImaging
HeadandNeckImaging
MusculoskeletalImaging
NuclearMedicine
OB/GYNUltrasound
SpineImaging
ThoracicImaging
VascularandInterventionalImaging
Thierry A.G.M. Huisman, MD, EQNR, FICIS Renee Flax-Goldenberg, MD
Medical Director Clinical Associate
Division of Pediatric Radiology; Division of Pediatric Radiology
Professor of Radiology The Russell H. Morgan Department of Radiology
The Russell H. Morgan Department of Radiology and Radiological Science
and Radiological Science Johns Hopkins Hospital
Johns Hopkins Hospital Baltimore, Maryland
Baltimore, Maryland
Aylin Tekes, MD
Jane Benson, MD Assistant Professor of Radiology
Assistant Professor of Radiology and Pediatrics Division of Pediatric Radiology
Division of Pediatric Radiology The Russell H. Morgan Department of Radiology
The Russell H. Morgan Department of Radiology and Radiological Science
and Radiological Science Johns Hopkins Hospital
Johns Hopkins Hospital Baltimore, Maryland
Baltimore, Maryland
Melissa Spevak, MD
Assistant Professor of Radiology
Division of Pediatric Radiology
The Russell H. Morgan Department of Radiology
and Radiological Science
Johns Hopkins Hospital
Baltimore, Maryland
C A S E R E V I E W
Pediatric Imaging
SECOND EDITION
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PEDIATRICIMAGING:CASEREVIEW ISBN:978-0-323-06698-3
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Casereview:pediatricimaging.–2nded./ThierryA.G.M.Huisman...[etal.].
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ISBN:978-0-323-06698-3(pbk.:alk.paper) 1. Pediatricdiagnosticimaging–Casestudies.
I. Huisman,ThierryA.G.M. II. Ward,RobertJ.,MD.Pediatricimaging. III. Title:Pediatricimaging.
IV. Series:Casereviewseries.
[DNLM: 1. DiagnosticImaging–methods–CaseReports. 2. DiagnosticImaging–methods–Problemsand
Exercises. 3. Child. 4. Infant. 5. Pediatrics–methods–CaseReports. 6. Pediatrics–methods–Problems
and Exercises. WN 18.2 C337 2011]
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INTRODUCTION
ThisisanewcollectionofcasesforthepediatricradiologyCaseReviewSeries.Iwaspleasedto
collect and arrange these cases upon the friendly invitation by Dr. David Yousem. The collec-
tion will be part of the second edition of the Requisite Series of Pediatric Radiology. The pur-
pose of the Case Review Series is a didactic one. It allows readers to explore, deepen, and
further develop their knowledge in a most fascinating area of imaging—pediatric radiology.
The cases match the daily routine practice and will stimulate readers to further
diagnosticinvestigationusingtextbooks,journals,andtheInternet.Studyingthesecasesshould
be fun.
The creation ofanattractivecollection ofcases was only possiblewith the help ofmygifted
and dedicated colleagues from the pediatric radiology medical staff: Drs. Jane Benson, Renee
Flax-Goldenberg,MelissaSpevak,andAylinTekes.Theyallcontributedfromtheirfieldsofinter-
est and expertise. We tried to cover the spectrum of pediatric radiology to the best of our
abilities. I thank all my staff pediatric radiologists for their contributions, help, and patience.
Another essential factorin completing this case review isthe factthat we are supportedand
intellectually challenged by brilliant pediatric physicians at the Johns Hopkins Hospital and
University,withtheirprofessionalrequestsandstimulatingdiscussionsatourdailyjointconfer-
ences. This interdisciplinary culture has its roots in Johns Hopkins’ four core values: (1) excel-
lenceanddiscovery,(2)leadershipandintegrity,(3)diversityandinclusion,and(4)respectand
collegiality.Theseareasvalidtodayastheywereatthefoundingofourhospitalandourschool
of medicine in the late nineteenth century. Our clinical colleagues are aware of the value and
expertuseofourimagingtoolsinthediagnosisandtreatmentoftheirpatients.Ourthanksgoes
toboth:toourcolleaguesandtotheirpatientswhosoughthelpatourinstitutionandprovided
us with their imaging data.
I am thankful to my most supportive and dedicated secretary, Iris Bellamy, for her effort in
arranging all the text and illustration material.
Lastbutnotleast,IwouldliketoexpressmygratitudetomywifeCharlotte,especiallyforher
patience, support, and encouragement. And to our wonderful children, Max, Laura, and Emily,
who are the source of my daily inspiration. They remind me that the goal of our professional
work with children is to strive for the betterment of our common future.
Ihopethatstudyingthiscasecollectionwillbeasenjoyableforreadersasitspreparationwas
for its authors.
Thierry A.G.M. Huisman
May 2010
v

Opening Round
C A S E 1
Tractography
1. Summarize all imaging findings seen on this neonatal magnetic resonance image (MRI).
2. What is your diagnosis?
3. In which order does the corpus callosum (CC) develop?
4. In which malformation is the posterior CC developed without an anterior part?
3
A N S W E R S
C A S E 1
Diagnosis: Corpus Callosum Agenesis data. On coronal imaging the combination of the sepa-
1. CompletelackoftheCC,radiatingappearanceofthe rated lateral ventricles, the medial impression of these
medial brain sulci, no inversion of the cingulate ventricles by the Probst bundles, and the shape of the
gyrus, trident shape of the ventricles on coronal adjacent third ventricle mimic a trident or Texas long-
imaging, malrotated hippocampi, high-riding third horn cow. Because the CC is one part of the commis-
ventricle, prominent adhesion interthalamica, sures connecting both hemispheres, the remainder of
colpocephaly, parallel course ofthelateral ventricles the commissures should be studied for additional mal-
on axial images, Probst bundle (tractography) that formations. The hippocampi may be malrotated; the
runs in the anteroposterior (AP) direction without anteriorcommissure may belacking.In50%ofchildren
left-right crossing, mild ventriculomegaly. a CC agenesis is part of a more extensive malformation
(e.g., Dandy-Walker malformation, Arnold-Chiari II mal-
2. Complete agenesis of the CC.
formation, septooptic dysplasia). In addition, migra-
3. Genu, truncus, splenium, and rostrum. tional abnormalities are frequently encountered. Ruling
out additional malformations is essential; doing so will
4. Lobar and semilobar holoprosencephaly.
determine a functional and cognitive prognosis. Clini-
cally, an isolated CC agenesis may be an incidental
Reference
finding on an MRI. If additional malformations are pres-
Hetts SW, et al: Anomalies of the corpus callosum: an
ent, then seizures, a developmental delay, and a hypo-
MRanalysisofthephenotypicspectrumofassociated
thalamic-pituitary dysfunction may result. CC agenesis
malformations,AJRAmJRoentgenol187:1343–1348, should be differentiated from secondary injury of the
2006.
CC. For example, a severe atrophy of the CC resulting
from an extensive periventricular leukomalacia should
Cross-Reference
not be confused with a primary CC agenesis. In addi-
Blickman JG, Parker BR, Barnes PD: Pediatric radiol- tion, it is important to remember that the only excep-
ogy—the requisites, ed 3, Philadelphia, 2009, Mosby, tion to the anterior-to-posterior rule of development is
p 222.
asemilobarorlobarholoprosencephaly.Inthesemalfor-
mations the posterior CC may be present without the
Comment
genu or anterior trunk of the CC.
The CC is the largest commissure (bundle of white
matter tracts) connecting both cerebral hemispheres.
Additional hemispheric connections are the anterior
commissure and the hippocampal commissure. The
CC has a complex, programmed anterior-to-posterior
development starting with the genu and followed by
the truncus and splenium. The rostrum of the CC is the
finalsegmenttodevelop.AgenesisoftheCCisobserved
on imaging with multiple, characteristic anatomic
sequelae. Most of the classical sequelae are demon-
stratedinthiscase.ThelackoftheCCisusuallyevident
in the midline, sagittal slice. In addition, the sulci along
the medial surface of both cerebral hemispheres show
a typical radiating appearance converging to the third
ventricle. The third ventricle may be enlarged and
extendinterhemispherically.Inrarecases thethirdven-
tricle may reach the vertex, or an associated interhemi-
spheric cyst may be revealed. On axial imaging the
lateral ventricles reveal a parallel course because the
CCislacking.Inaddition,frequentlytheoccipitalhorns
oftheventriclesareenlarged(colpocephaly).Thefibers
that cannot cross the midline usually realign along the
medial contour of the lateral ventricles and run in an
anterior-to-posterior direction. These fibers are known
as Probst bundles and can easily be recognized on trac-
tographyreconstructionsusing diffusiontensor imaging
4