18.

Thefundamentalsofpediatricradiology
Author:vaKis
SemmelweisUniversity1stDepartmentofPediatrics,Budapest

18.1.Differencesbetweenpediatricandadultradiology
Thechildisnotasmalladultitmightseemasaclich,butinfactitisthebasictruth.Childrenandadolescentsufferfromdifferentdiseasesthanadultsandrequire
differenttherapiesaswellasalteredimagingapproaches.
Thestrategiesfordiagnosticimagingaredifferent,althoughthemodalitiesarethesameorsimilartothoseusedinadultradiology.Thesequenceofmodalitychoice,
someofthetechnicalparametersandthefollowupprotocolsaredifferentinpediatricradiology.
Thenumberonedifferenceisradiationsafety.Childrenareespeciallysensitivetoionizingradiation.Immaturetissuesareextremelysensitivetoradiationandthereis
nominimalsafetydosagethatisconsideredabsolutelyharmless.Tissuesingrowthandtheredbonemarrowthattakesupmostofthebonemarrowtissueatthis
agegroupareespeciallysensitivetoradiation.Becauseofthesmallerbodysize,thegonadsareclosertotheirradiatedzones.Moreover,becauseofthelongerlife
expectancyinchildren,thecumulativedoseofnaturalandartificialradiationmeanhigherriskforthedevelopmentofmalignantdiseases.Thebestprotectionisto
minimizeortocompletelyavoidtheuseofionizingradiationinchildren.This,ononehandmeansstrictcontrolandsupervisionoftheindicationsofXrayandCT
examinations,ontheotherhand,whenpossible,theuseofnonionizingexaminationssuchasultrasoundorMRIarepreferred.Theotherperspectiveofradiation
safetyistodecreasethenumberofXrayexpositionstothebareminimum,meaningthatunnecessaryrepetitions,comparativeormultiangularexaminationsshould
beavoided.CTexaminationsshouldonlybeperformediftheyareabsolutelynecessaryandifsowiththeuseofspecial,lowdoseprotocols.
ThesocalledALARAacronymstandsforAsLowAsReasonablyAchievable,thereforeitmeansthatoneshouldusethelowestdosageofradiationpossible.This
pointofviewcanneverbeneglectedinpediatricradiology.
Thischapterismeanttointroducethemostimportantradiologicmodalitiesinchildrenandadolescentcaredifferingfromtheadultradiology,aswellastogivean
overviewofthemostcommondiseasesinashortandbasicmanner.

18.2.Radiologicdiagnosticsofthechest
18.2.1.Thenormalnewbornchest
Normalnewbornlungs:anewbornschestgoesthroughsomefundamentalchangesduringthefirstdaysofextrauterinelife.Theheartisrelativelyrounded,
characterizedbythedominanceoftherightside.Thecardiothoracicindextakeninamidinspiratorystateisbetween0.550.62.Expiratorystatecanleadto
diagnosticmistakes.
Thymus:isusuallymadeupoftwoasymmetricallobes,situatedintheanteriorsuperiormediastinumandshowsagreatvariabilityofbothsizeandshape.Itdoesnot
causeanycompressionontheneighboringorgans.Onultrasoundexaminationitappearsasahomogenoussolidtissue,relativelymorehypoechoicthanthethyroid
gland.Thediaphragmisabitmoreelevatedinmidinspiratorystateitsarchisbetweenthe89thribonthebackandatthe6thribinthefront.
Bonythorax:theribsarehorizontalandthesagittalandhorizontaldiametersofthechestareveryclosetoeachother.

1.a.Expiratorystate:thetransparencyofthelung
isdiffuselydecreased.

1.b.Inspiratorystate,thelungistransparent,theheartis
normalsized.Ribsrunhorizontallyininfants.

2.Thymushasacontouronbothsides.
Healthynewborn.

18.2.2.Afewdiseasesofthenewborns
Wetlung,transitoricustachypnoe.Fetalliquidsinthelungarenotproperlydrainedbythevenousandlymphaticvessels;thenewbornwillshowsignsofdyspnea
andtachypnea.OnXray,thechestappearshyperinflated,withdecreasedtransparencyandwitharelativecardiomegaly.Thesesignsusuallydisappearwithin72
hours.
IRDS(Idiopathicrespiratorydistresssyndrome).Preterminfants,youngerthan34weeks,haveimmaturelungswithsurfactantshortagethatleadstoalveolar
insufficiency.Thebreathingdisorderprogresseswithtimeastachypnea,dyspnea,cyanosisandgruntingoccur.OnXrayimagestherespiratoryvolumewillregress
andadiffusereticularnodularpatterncanbeobserved,alsowideairbronchogramswillappearrunningtotheperipheries.Thecontoursoftheheartwillbeblurredor
evenacompletelossoftransparencyisvisible(stagesIIV).Surfactantadministeredintimewillresultinimprovedradiologicpicture.
Meconiumaspirationsyndrome(MAS).Itisfrequentlythediseaseoftermandposttermnewborns.Thefetusdefecatesmeconiumtotheamnioticfluidthatis

aspiratedatbirth,anditcauseschemicalpneumonitis.Ontheradiographthisisdepictedwithcoarsepatchyandstreakyalveolarshadows.
Bronchopulmonarydysplasia(BPD).Itisthepulmonarydamagethatoccursinimmaturenewbornsduetoprolongedperspiration.Itsradiologicpicturedependson
thestageofthedisease,earlysignsofBPDareundistinguishableformIRDS.Inlaterstages,thelungishyperexpandedwithpronouncedcentralreticularpattern.
Atelectasisisafrequentcomplicationthatpromotestheappearanceofinfectiousdiseases.

3.Whitelung.IRDS.IV.

4.Asnowstormlikenodularpatchy
infiltrateonbothsidedofthelung.
Meconiumaspiration.

5.Thebasallobesofthelungare
inflated,onbothsidesthereisan
irregularreticularpattern.BPD.
6.Intestinalshadowsinthe
leftsideofthechest,the
midlineisdislocatedtothe
right.Leftsideddiaphragm
hernia.

Congenitaldiaphragmhernias.Itistheresultofabnormaldiaphragmdevelopment.Itsradiologicpictureisinfluencedbyitsseverity,localization,andtimeof
duration.Leftsidedherniasaremorefrequent(alsocalledBochdalekhernias).Thenewbornsuffersfromrespiratoryinsufficiency,intestinalanddislocatedheart
soundscanbeheardabovethechest,theabdomeniscollapsed.TherightsideddiaphragmherniaisalsocalledtheherniaofMorgagniandcausesalesssevere
clinicalpicture,manytimesdiscoveredaccidentallyontheXray.Onultrasoundthemissingdiaphragmandaherniatedportionoftheliverisseen.

18.2.3.Pneumonia.
Incaseofcharacteristicclinical,auditoryandpercussionexaminationresults(crepitation,bronchialbreathingsounds,dullnessatpercussion)aradiologicexamination
isnotevennecessary.
Radiography:forthemajorityofpneumoniasasinglePAchestXrayisenoughforthediagnosis.Theinitialexaminationwithinthefirst24hoursofonsetisgenerally
negative,ifitsclinicallynecessary,controlexamistobeperformed.However,ifthetreatmentforbronchopneumoniaimprovestheclinicalsymptomsXraycanbe
neglected.Thefinalconfirmationthattheinfiltratehasbeenresolvedisalwaysdocumentedonaradiograph.Incaseofpleuropneumoniasultrasonographyis
capabletocontrol,toanalyzeandtofollowthecourseofthepleuraleffusion.Therefore,manycontrolXrayexamscanbesubstitutedwithUS.
Xrayingeneralisnotappropriatetofullydeterminetheetiologyofpneumonia,butcanbeindicativeinsomecases.
StreptococcusBpneumonia:.isanacquiredinfectionafterbirthofmaturenewbornsanditcanmimicIRDS.ThedifferencetoIRDSisthecoarserreticularnodular
appearanceaccompaniedbypleuraleffusionatmanytimes.Sometimesscatteredorconfluentperihilarpatterncanberecognized.
Staphylococcusaureuspneumonia:isacommonbacterialpneumoniainsmallbabies.ItsclinicalpictureonXrayisaccompaniedbycoarsenodularorconfluent
infiltrations,withfrequentpleuraleffusions.Thepneumonicnodulesconsolidatefastandformpneumatocelesthatcangrowfurtherandpersistforalongertime.
Healingusuallylastsformonths.
Roundpneumonia:isacharacteristicpediatricdisease.TheroundshapedinfiltrationmimicsatumorontheXrayimage(neuroblastoma,bronchogeniccyst).Acute
development,afeverishstate,andairbronchogramappearancewithintheinfiltratehelpwiththedifferentiation,aswellastheregressionoftheinfiltratebytheend
ofthetherapy.ThemostcommonbacteriumisStreptococcuspneumoniae.Furtherimaging(CT)israrelynecessary.

7.Pneumatocelesintherightupperlobe.

18.2.4.Airwayforeignbody

8.Almostcompleteresolutionwithinone
month.

9.aAtexpirationtherightsideis
expanded.

9.b.Atinspirationthemidlineisshiftedto
theright.Holzknechtsign:foreignbodyin
therightbronchus

Childrenputanythingintheirmouthand,thereforefromtimetotimeaccidentalaspirationstendtooccur.Thesymptomsofacuteaspirationareveryapparent.A
pneumoniarecurringatcertainlocalizationishighlysuggestiveofchronicaspirationofaforeignbody.Hence,theroleofradiologyismoreimportantinchroniccases
ofaspiration,wherepatienthistorydoesnotnecessarilyindicateforeignbodyaspiration.
Xrayexamination:aspiratedforeignbodiesarerarelyXrayabsorbing,andthereforerarelyappearontheradiographs.AnegativeinspiratorychestXraydoesnot
excludethepossibilityofaFBaspiration.MostFBscauseocclusiononthelevelofthebronchi,whichmeansthatininspirationaircangetfurtherthantheFBbutat
expirationitwillblocktheairway.Thus,onexpiratorychestXray,theaffectedlungsegmentwillbepneumatic;thediaphragmwillbepushedlowerontheipsilateral
side,whileatinhalationthemidlinewillbeshiftedtowardstheaffectedside(Holzknechtsign).InsuspicionofFBaspiration(evenifchestradiographisnegative)
bronchoscopyiscompulsory.

18.3.Gastrointestinal(GI)tract
18.3.1.Examinationmethods:
Preparation:Whenperformingapassageexaminationinnewbornsorsmallinfantsthelastfeedingisskipped.Astartingabdominalplainfilmradiographis
mandatorybeforeeachpassageexamination(toidentifythedistributionofintestinalgas,toruleoutfreeabdominalair,orintestinalwallpneumatizationandto
locatethelevelofobstruction.)Plainabdominalxrayisinmanycasesinformative,whethercontrastadministrationisreallynecessary,andifanimmediatesurgeryis
unavoidable(e.g.:freeabdominalair,orincaseofaproximalatresiainnewborns).Incasesofcontrastexaminations(passageexamorcolonenema)thepreferred
contrasagenthasalowosmolalityandisabsorbable.

18.3.2.Afewimportantdiseases
Esophagealatresia:iscommonlylocatedattheleveloftheupper/middleesophagealborderandissometimesassociatedwithtracheoesophagealfistulas.
Newbornsareunabletoswallowtheirsalivaandthediagnostictubegetsstuckintheesophagus.Themostcommonformisatresiawithalowerfistula.In50%ofthe
casesotherabnormalitiesarepresent;aspartofthesocalledVACTERLsyndrome(vertebral,anal,cardiac,tracheoesophagealfistula,renalandlimb)various
additionalabnormalitiescanbeobserved.
Xrayexamination:anXrayabsorbenttubeisvisibleintheobstructeddiverticulaoftheesophagus.Incasesofalowerfistula,theintestinesareaerated,the
accompanyingcostalandvertebralabnormalitiescanalsobeobserved.
Hypertrophicpyloricstenosis(HPS).Asaresultofthehypertrophyandhyperplasiaofthepyloricmusculatureasecondarystenosiscanoccur,thatusuallyleadsto
symptomaticstatesin36weeksoldinfants.Itprimarilyoccursinboysasfrequent,progressive,nonbilious,projectilevomiting.Onultrasonographyanenlarged
(15mmormore),thickwalled(3mmormore)pyloruscanbeseeninbothlongitudinalandinaxialcrosssection.

10.Thetube
insertedinthe
esophagusturns
backintheheight
ofthe4thThoracic
vertebra,the
intestinesarefilled
withgas.
Esophagusatresia
withlowerfistula.

11Thetube
insertedinthe
esophagusturns
backintheheight
ofthe2nd
Thoracicvertebra.
Theabdomenis
gasless.
Esophageal
atresiawithout
fistula.

12a:AbdominalUS:thepyloriccanalis
extended,itswallisthickened.Pylorus
stenosis,longitudinalview.

12.b.Axialcrosssection.

Duodenalobstruction.Thecauseofproximalobstructionisprimarilyduodenalatresiaorstenosis.UsuallyUSisabletodepictthedistendedstomachandduodenum
duringintrauterineUSexaminationasacysticmass,whileotherintestinesarecompletelyfreeoffluids.Vomitingoccursinthefirsthoursofextrauterinelife.Plain
abdominalradiographincasesofatresiawillrevealthesocalleddoublebubblesign,wherethestomachandtheduodenumaredistendedbutondistalsegments,
theintestinesaregasfree.Incasesofstenosis,thedistalintestinalloopswillalsoshowsomeaircontent.Otherexaminationsareunnecessaryandaircanbeusedasa
negativecontrastmaterial.
Malrotationvolvulus.Duringthenormaldevelopmentoftheintestinaltract,theintestinalloopsmakethree90degreeclockwiserotationsaroundthemesenteric
superiorartery(MSA.)Ifthisrotationonlypartiallyoccursduringtheembryonicdevelopmenttheintestinesremaininanonrotationalormalrotationalposition,the
mesentericrootwillbeshorterandthececumwillbeweaklyattached.Thisanatomicpositioningcanbesymptomfreethroughoutalifetime,butitpredisposesfor
volvulus.Volvuluscanoccuratanyage,butitismostfrequentinthefirstmonthsoflife,whenitabruptlyoccurswithacutebiliousvomiting.Inthisstatethe
intestinesaroundthemesentericroottwist,endupinacompleteobstructionthatcanleadtoarapiddeathoftheintestines.Ultrasonographycandepictthe
mesentericsuperiorvein(MSV)coileduparoundtheMSA,socalledwhirlpoolsign.
DuringXrayexaminationthecontrastmaterialdoesnotprogresstothejejunalloopsoritshowsacorkscrewsignontherightsideofthevertebraeasitpilesupin

thetwistedintestinalloops.

13.Distendedstomachand
duodenalbulbus,Double
bubblesign.Duodenal
atresia.

14.WhirlpoolsignThemesenteryandthesuperior
mesentericvein,asitcoilsaroundthesuperior
mesentericartery.Volvulus.USexam.

15.Contrastmaterial
emptiesthestomach
slowly,smallintestines
arefoundontheright
sideoftheabdomen.
Malrotationvolvulus.

16.Nonused,narrow
colon.Newborn,meconium
ileus

Meconiumileusoccursin10%ofchildrenwithcysticfibrosis(CF),andalmostallofmeconiumileuscasesarearesultofCFdisease.Itischaracterizedbyvomitingand
abdominaldistention,asthemeconiumcannotbedefecated.Onplainabdominalradiographtheintestinesaredistendedwithoutanyairfluidlevelsduetothe
adhesivenatureofmeconium.Colonenemaexaminationwithwatersolublecontrastmaterialwillshowamicrocoloninwhichthemeconiumwillcausecontrast
fillingdefectsresemblingsmallpearls.Contrastmaterialthatreachestheterminalileum,andtherepetitionoftheenemascansometimessolvetheileus.
Invagination.Adistalintestinalloopinvaginatingtoaproximalintestinalloopcanresultinamechanicalintestinalobstruction,andcauseischemicdamage.Itmost
frequentlyoccursininfants(324months)withrecurring,coliclikecomplaints,distendedintestines,apalpablemassandwithfrequentvomitingandbloodystool.
Invaginationrequiresimmediatediagnosisanddesinvagination.USexamrevealstheinvaginatedintestinesasatargetsigninaxialcrosssectionandlookslikea
pseudokidneyinlongitudinalcrosssection.Thetherapyishydrostaticorpneumaticdesinvagination.Perforationand/orperitonitisareabsolutecontraindicationsto
theseprocedures.HydrostaticdesinvaginationcanbeperformedunderfluoroscopyorwithUSguidanceandisconsideredsuccessfulifairorthecontrastmaterial
appearsintheterminalileumandtheinvaginatedloopdisappears.Iftheseeffortsdonotsucceed,surgicaldesinvaginationisneeded.

17.Targetsign.Invagination..

18.abcDesinvagination
withair.

18.b.Arrow:invaginated
segment.

18.c.Successful
desinvagination

Necrotizingenterocolitis(NEC).Itisasevereintestinalnecrotizingdiseaseofthenewborns.Itusuallyoccursasearlyasthefirst10daysoflife,butcanhappeninthe
firstfewmonthsafterbirth.Vomiting,distendedintestines,bloodystool,acidosis,peritonitisandperforationarefrequentfindings.PlainabdominalXraycanbe
noninformativeintheearlystagesofthedisease;laterdistensionindicatestheseparationofloopsduetowallthickening.Often,airbubblesappearintheintestinal
subserosalorsubmocosallayers,ascharacteristicsignsofintestinalpneumatosis.Theintramuralaircandiffusetothemesentericveinsandappearintheportal
circulationintheprojectionoftheliver.Freeabdominalairisindicativeofperforationandrequiressurgicalintervention.USexaminationcanrevealthese
characteristicsofthediseasebeforeXrayisindicative.UScandepictthickenedintestinalwall,portalandintramuralair,abdominalfreefluidorabscesses.
Hirschsprungdisease.Inthisdiseasetheganglionsofthedistalcolonaremissing.Thelackofinnervationofthecolonicsmoothmuscleresultsinspasticfunctional
obstruction.Thesymptomscanappearrightafterbirthwiththelackofmeconiumdefecationandsignsofobstruction.OnplainabdominalXraytheproximal
intestinesaredistendedwithorwithoutairfluidlevels,thedistalloopsaregasfree.Withcontrastenemathedistal,irregular,spastic,noninnervatedsegmentsand
theproximalprestenoticdilatationofthecoloncanbevisualized.

19.Distendedbowelloops.Air
isseenintheintestinalwall,
intestinalpneumatosis.
Necrotizingenterocolitis.

20.NEC,USexamination.Free
abdominalfluid,withdense
innerechos.Airbullblesinthe
intestinalwall:zebrasign
(arrow).

21.Thedistalsegmentof
thecolonisnarrow,irregular
(aganglionarsegment).
Transitionalzone(arrow)
andcompensatory
prestenoticdilatation.
Hirschsprungdisease.

18.4.Urogenitalsystem
18.4.1.Diagnosticmethods
Ultrasoundisthemethodofchoice,providesdetailedinformationofthemorphologyofthekidneysandtheurinarytract.Prenatalexaminationscanreadilydiagnose
mostofthelesionsattheintrauterineage.
Mictioncystourethrography(MCU).Isthegoldstandardfortheimagingofthebladderandthedistalurinarytractsaswellastheinvestigationofvesicouretralreflux.
Aurinarycatheterisinsertedandcontrastagentisadministeredwithfluoroscopiccontrol.
Sonocystography.Ultrasonographiccontrastmaterialisadministeredtothebladderthroughacatheter.Thecontrastmaterialincreasestheechogenityoftheurine
(fluid)andincasesofrefluxthischangecanbedetectedintheureterandthepyelon.ThismethodinmostcasescansubstituteMCU,however,theurinarycatheter
stillremainsaninvasivestepoftheexamination.
Nuclearmedicineexaminations(seethere)
MRurography(seethere)

18.4.2.Someimportantdiseases
Congenitalobstructiveuropathies.Congenitalabnormalitiesofkidneydevelopmentcanoccuratanyleveloftheurinarytract.Itsmostcommonsingisurinarytract
dilatation.Theroleofimagingisin:diagnosingthecause,thelevelandthestageofdilatationanddifferentiatingtheobstructivecasesformnonobstructiveones.
Uretropelvicobstruction(UPO).Uretropelvicjunctionstenosiscanbeanacquiredoraninnatestate,withdifferentdegreesthatleadtothedysfunctionofexcretion
ofurinefromthepyelontotheproximalureter.Itisthemostfrequentformofobstructiveuropathy.USexaminationevenatprenatalstatescandiagnosetheurinary
tractdilatationthatcanbeuniorbilateral,alwayswithoutureterdilatation.
Isotopeexamination:theisotope(Tc99mMAG3)injectedwithdiureticscanbeusedtoanalyzerenalfunction.
Distalurethralvalve(subvesicalobstruction).Itisthemostsevereformofobstructiveuropathy.Innewbornboysthevalvedysfunctioncanleadtobilateral
obstructionwithhydronephrosisandhydroureter.Urinationcanonlyoccurintermittently.Thebladderwallisthickened,trabecularandrefluxisfrequent.The
proximalurethraisdistendedaswell.

22.Thecalicesandthepyelonofthekidney
aremarkedlydilated,theparenchymais
thinner.Severehydronephrosis.Theureteris
notvisible.Pyelouretralstenosis.

23.Miction
cystourethrography.Asmall
diverticulaisseenontheright
side,theproximalurethrais
dilated,beneathisafilling
defect.Subvesical
obstruction,dorsalurethral
valve.

Vesicouretral(VU)reflux.Refluxstandsforthereentryofurinefromthebladdertotheureterandthecollectingsystemofthekidneysduetotheinsufficiencyofthe
uretrovesicalvalve.Thiscanleadtoatransientorapermanentdilatationoftheurinarytracts.UScanonlyraisesuspicionforUVrefluxthroughindirectsignssuchas
thickenedpyelonwall,smallkidney,thinnerandblurrycorticomedullaryjunction,unevenparenchyma,thickenedbladderwall.RefluxcanbedepictedwithMCUor
sonocystogrphy.Refluxisinternationallycategorizedin5levels(IV).Itsspecialformistheintrarenalrefluxthatappearsintheupperorlowerpoleofthekidney.

24.a.

24.b.

24.c.

24.d.

24.e.

Mictioncystourethrography.a.Refluxintheleftnormaldiameterureter.VURl.s.Gr.I.b.Bothuretershaveanormal
diameterastheyrefillwiththecontrastmaterialrefluxingfromthebladder.VURl.u.Gr.II.c.Thereisaslightlydilated
rightureterandcollectingsystemintherightkidney,thecalicesarewidened.VURl.s.Gr.III.d.Dilatedureterand
collectingsystemcanbeseenontheleftside.VURl.s.Gr.IV.e.Therightureterismarkedlydilatedandelongatedthe
pelvicalycealsystemisalsomarkedlydilated,thecalicesarerounded,contrastmaterialappearsinthetubulesaswell.
VURl.d.Gr.5.withintrarenalreflux.

18.5.Abdominalmasses
Neuroblastoma.isatumorthatdevelopsatanypartofthesympatheticnervoussystem.Therefore,inover90%ofthecasestheurinarycatecholaminelevelsare
elevated.Itisthemostfrequentextracranial,solidtumorinchildrenandhasitshighestmalignancyratewithinthefirstyear.Itismostcommoninchildrenaged15
years,appearsasapalpableabdominalmass,withfever,hypertension,andanemia;incasesofbonemetastases,bonepainandlimpingarecommon.US
examinationrevealsawellcircumscribed,echogenicmassusuallycrossingthemidline,dislocatingthekidney;itisfrequentlycalcified,highlyvascular,surrounding
andcompressingtheabdominalvessels.Inprogressivecasesliverandnodalmetastasescanbefound.Thetumorcanalsobesolid,homogenousandwithasmooth
margin.TheadrenalregioninnewbornsiswellvisualizeablewithUS,butatolderagesonlymajorlesionscanbedepicted.CT/MRIexamination:candepictalarge
sized,irregularshaped,extrarenalmass,withfrequentnecrosis,hemorrhageandcalcifications.Thelesionsshowaheterogeneouscontrastenhancement.
Nuclearmedicineexamination:MIBGscintigraphyisbasicallya100%specificbutitssensitivityislower,becausenonMIBGuptakingtumorsexistaswell.

25.USexamination,longitudinalview.Above
therightkidney,intheadrenalregionasolid,
slightlyinhomogeneousmasscanbeseen.
Neuroblastoma.

26.MRIexamination,axialT2weightedimage.Irregular,largesolid,
inhomogeneousretroperitonealtumorisseen.Neuroblastoma.(withthe
courtesyofDr.GborRudas)

Wilmstumor.Itisthemostcommonkidneytumorinchildhoodthatappearsbetween25yearsofage.Itisusuallyonlynotedwhenthetumorispalpableasan
abdominalmass.Hematuria,hypertension,vomitingandabdominalpainarealsopartoftheclinicalpicture.USexaminationisabasicmethodinboththediagnostics
andthefollowupofthetumor.Thetumorisnormallyseenasahomogenousoraninhomogeneousmass,dislocatingthepyelonandthesurroundingretroperitoneal
bloodvessels.Itisimportanttoruleoutanylesionintheotherkidney.MRIexamination:givesapictureoftheentireabdomen,kidneysincluded.Nodalmetastases,
tumorthrombusarewelldepictable.CTexamination:istobechosenifMRIisnotavailable.Thetumorshowsaninhomogeneouscontrastenhancementand
pulmonarymetastases(invisibletoxrayexamination)arealsodepictable.

27.Asolid,echogenicmassarisingfromthe
rightkidney.Wilmstumor.AbdominalUS.

28.MRIexaminationaxial,T2weightedsequence.Asolid
massarisingfromtherightkidneyandfillingouttheright

29.CTexaminationafteriv.contrastadministration.
Mostlyhypodensemassarisingfromtheleftkidney.

sideoftheabdomen,withperipheralfollicularcystic
components.Wilmstumor.(withthecourtesyofDr.
GborRudas)

Wilmstumor.(withthecourtesyofDr.Z.Kardi)

18.6.Centralnervoussystem(CNS)
Duetothevastnessofthisfield,inthissegmentwecanonlyconsidersomefundamentallydifferentdiagnosticmethodsandafewCNSdiseasestypicaltonewborns
andinfants.
ThemostimportantdiagnosticmethodoftheCNSofinfantsandchildrenisMRI.(seethere)

18.6.1.Specialimagingmethodsofnewbornsandinfants
Cranialultrasonography:isthefirstmethodofchoiceinbrainparenchymaexaminations.Itcanonlybeperformeduntiltheclosureofthefontanelles(810months)
(anteriorandposteriorfonatnelles,mastoidalandtemporalregion).Examinationsrequireahighfrequencyconvextransduceraswellasalinearone.Vertebral
ultrasound:canonlybeperformedinthefirst23monthsoflifeuntiltheclosureofthevertebralarch,withalineartransducer.

30.a.

30.b.

30.c.

30.d.

30.ad)Cranialultrasound.Normalnewbornbrain.ab.Coronal,cd.Sagittalviews.

USexaminationisalsocapableofdiagnosingandfollowingupcerebralcomplicationsofprematureinfantse.g.:germinalmatrixhemorrhage,periventricular
leukomalacia(PVL),hydrocephalusandforthescreeningofcertaindevelopmentaldisorders(corpuscallosumagenesis,Galeniveinaneurysm,DandyWalker
syndrome).However,wehavetorememberthatUSisnotsensitivetoallabnormalitiesormoresophisticatedlesions.Metabolicdiseasesandsomehemorrhagesetc.
arenotalwaysdetectablewithUS.ItisaveryusefulmethodbutitslimitationshavetobekeptinmindandwhennecessaryMRIistobeused.

31.NormalspinalUS,longitudinalview(longarrow:medullarcone,small
arrowvertebralbody.)Newborn.

32.USexamination,sagittalview.Radialpatternof
thegyri.Corpuscallosumagenesis

33.a.USexamination,coronal
view.Ontherighttemporal
lobeasmallechogenicarea
canbeseen.

33.b.MRI,axialview,diffusion
sequence.Rightsided,3.5cmarea
withrestricteddiffusion.Acuteinfarct
intheparietotemporalregion.(SE,
MRKK,withthecourtesyofdr.
GyrgyVrallyai).

33ab.Cerebralinfarct,newborn.

18.6.2.Somediseasesofpreterminfants
Germinalmatrixhemorrhage.Itisahemorrhagetypicallyoccurringinprematureinfants.Thereare4stagesdistinguished(subependymalbleeding,ventricular
hemorrhage,ventricularbleedingwithhydrocephalus,andthelatter+parenchymableeding).
Hydrocephaluscanbeafrequentcomplicationaftergerminalmatrixhemorrhage,butatabouthalfofthecasesitresolvesspontaneously.USexaminationisa
methodforitsdiagnosticsandalsoforitsfollowup.
Periventricularleukomalacia(PVL).Itisusuallyabilateralporenchephaliccysticdiseaseintheperiventricularwhitematterthatdevelopsduetoischemicdamagein
preterminfants.

34.CranialUS,coronalview.Moderate
ventriculardilatationwithinhomogeneous
bleedingintheventralhornoftherightlateral
ventricle.GradeIII.hemorrhage.

35.CranialUS,coronalview.Theposterior
hornsaredilated,hemorrhageispresentinall
ventricles.Leftsidedperiventricular
parenchymableeding.GradeIV.hemorrhage.

36.CranialUS,sagittalview.Dilatedventricle,
periventricularcysts.PVI.

18.6.3.Maturenewborns
Hypoxicischemicencephalopathy(HIE).Hypoxicischemia,orperinatalasphyxiaisthemostcommoncauseforsevereneurologicabnormalitiesofthenewborns.
Theroleofimagingistodeterminethegradeandextentofthedamageandtomonitorthedamagedlesionasearlyaspossible.Ultrasonography:insomecasesin
theacutestagesofthediseasecanvisualizefocalordiffusehyperechogenicperiventricularorbasalganglialesions.Inchronicstagesperiventricularcysts,
encephalopathy,hydrocephalusandwidenedsubarachnoidspacecanbedetected.MRIexaminationisthemostsensitivemethod,asitcandepictchanges
undetectablebyUS.IntheacutestageMRspectroscopyisverysensitivetothedamagethatisindicatedbylactatepeakandadecreaseinothermetabolites.
Diffusionweighedimagingisthemostsensitivewaytodetectcytotoxicedemarightaftertheischemicinsult.

18.6.4.DevelopmentaldisordersoftheCNS
Theyareamongstthemostcommondevelopmentaldisorders(1:100births).Thespectrumisbroad,coveringsmall,focalcorticaldysplasiaaswellascomplex
syndromes.Theearlydetectionofthesedevelopmentaldiseaseshelpsindeterminingthedegreeofthelesionandmighthelpinthetherapy,aswellasinthe
prognostics.Itplaysafundamentalroleintheplanningoffuturepregnancies.USexaminationisonlygoodforpartialdiagnostics;MRIisthebestchoiceforthe
detectionofcorticalmalformations,migrationalanomaliesandmyelinationdisorders.

18.6.5.Supraandinfratentorialbraintumorsinchildren
Brainneoplasmsarethesecondmostcommontumorsinchildren,afterleukemia.
Theirsymptomsdifferfromtheonesofadulthood,ononehandbecauseweencounterdifferenttypesoftumorsinchildrenandontheotherbecausethebony
suturesarestillnotclosedinthisagegroup.Braintumorsbelowtheageof2tendtobeprimarilysupratentorialinlocalization,whileinagesbetween2and10years
theyaremostlyinfratentorial.Above10yearsofagethesupraandinfratentorialtumorratioisbasicallythesame.BeforebrainsurgeryMRIexaminationis
performedwithvarioussequencesandiv.contrastadministration,moreoverfunctionalMRIexamsmightbeusedascomplementarytechniquestohelpthecorrect
diagnosisandsurgicaldecisionmaking.Earlyphase(24hours)postoperativeMRIiscapabletoshowresidualtumors.USexaminationisoflimitedvalue,itcanbeused
inthefollowupofconsequentialhydrocephalus.

18.7.Musculoskeletalsystem

18.7.1.Diagnosticmethods(seethere)

18.7.2.Someimportantdisorders.

Osteomyelitis.Osteomyelitisstandsfortheinflammationoftheboneandthebonemarrow.Itsmostimportantsymptomsarefever,pain,erythema,swellingand
elevatedinflammatorylabparameters.
Innewbornsandpreterminfantsitisoftensymptomfreeandmultifocal.Earlydiagnosticsandtherapyareextremelycrucial,sincethedevelopingbonesmightsuffer
apermanentdamage.Under1yearofagetheepiandmetaphysisarerichinbloodvesselanastomosesthatprovideaspreadingroutefortheinflammationtowards
theepiphysisoreventothejointsortheadjacentbone.After1yearofagetheanastomoticconnectionsdisappearandthediseaseischaracteristicallymetaphyseal.
Rarely,butprimarydiaphysealandepiphysealosteomyelitiscanalsooccur.
Xray:doesnotshowanychangeswithinthefirst714days.Thefirstsignisfocal,unevenporosis.Infurtherstagessofttissueswelling,bonydestruction,osteolysis,
bonenecrosiscanoccurandevenlater,sequestrationandperiostealreactiontakesplace.Radiologichealingtakesmonths.Ultrahasonography:detectsearlysigns
beforeXrayexaminationdoes.Itcanquicklydepictsofttissueedema,periostealreactionandsubperiostealfluids.
Nuclearmedicine:offersamethodwitha90%andupsensitivityandspecificitytoosteomyelitis,howeverwithinthefirst6monthsoflifeisonlypartiallyreliablein
thediagnostics.Itshowsacharacteristicactivityincreaseinall3stagesoftheexamination.
MRI:candetectosteomyelitisinearlystages,andwithgreatreliability.Itsrateforidentificationandthedetectionoftheextentofthediseaseisbetween88100%.
MRIisabletoprovideagoodpictureofthephysis,epiphysisandtherelationoftheinflammationtothejointaswell(edema,exudates,abscess).

37.a.

37.b.

37.c.

37.d.

37.ad)Xrayoftherighthumerus.a.Rarefactionintheproximalmedialpartofmetaphysisoftherighthumerusearly
osteomyelitis.b.Twoweeksafterthelyticareahasgrown.c.1monthlaterscleroticregenerationhasbegun.d.4months
afteralmostcompletehealing.Osteomyelitis,infant.

38.US,longitudinal.Ontheproximalpartof
therightfemur,theperiostealsofttissueis
hypoechoic,theflowisincreased.
Osteomyelitis

39.a.

39.b.

39.ab.MRI,T2weightedandT1weighted,postcontrastaxialimages.Signalintensityincreaseandincreasedcontrast
enhancementinthebonemarrowoftheleftfemoralneck,.2yearsoldchild,osteomyelitis.(withthecourtesyofdr.
GborRudas).

Transitorycoxitis.Itisatransitionalinflammatorydiseaseofthehipjointthatcausespainandlimping.Thepainismanytimeslocalizedelsewhere;onthelimbor
theknee,leavinglimpingasanonlysymptom.USexamination:candepictsmallamountsoffluid.Eithera4mmwidefluidcollectionor2mmdifferencecomparedto
theotherlegareindicativeofinflammation.Thesynoviumisoftenthickened.

Rachitis.RachitiscanbecausedbyinsufficientvitaminDalimentation,adecreaseinmineraluptake(e.g.:prematureinfants)andvitaminDshortagedueto
malabsorption(coeliakia,cysticfibrosis)oradisorderinvitaminDproductionprocess.Itsclinicalsymptomsareverycharacteristic:thewristisswollen,apalpable
massorstrainisoftenfoundontheanteriorachoftheribs,theskulliscompressiblelikeapingpongball.Xrayexamination:thetypicalsignsofrachitiscanalways
befoundinthetransitionalossificationzone.Onwristradiographthedistalmetaphysisoftheulnaandtheradiushaveanirregularcontour,theyarehollowed,the
distancebetweentheboneandtheepiphysealcoreiswidened.
Rntgenfelvtel:acsipdysplasiaacsontosfemurfejmagjnakmegjelensigcsakindirektjelekbldiagnosztizlhat.

40.WristXray.The
distanceofthewrist
bonesand
radial/ulnarepiphysis
iswidened,uneven
andhollowed,at
partsthebone
densityisdecreased.
Rachitis

41.USexamination,hip,longitudinalview.The
lefthipsarticularspaceiswidened,withecho
freefluidinit.Transitorycoxitis.

42.USexamination.Normalnewbornhip
(arrow:hipbone.)

Hipdysplasia.Congenitalhipdysplasiaisamultifactorialdiseasethatoccursmoreingirls(1:9)andcausesthedislocationoftheheadofthefemur.Acetabularrim
developmentandconfigurationabnormalities,ligamentlooseness,musclecontracture,familyhistoryofhipdysplasia,orintrauterinebreechpositionhaveallbeen
mentionedaspossiblefactorscausinghipdysplasia.USexaminationiscapabletodiagnoseinfanthipdysplasia.Itisindicatediftheclinicalexaminationraises
suspicionorifriskfactors(breechposition,twinpregnancy,familyhistory,oligohydramnion,deformedlimb,neuromusculardisease)persist.UScanbeusedasa
screeningtool.Duetothephysiologicloosenessoftheligamentsbefore4weeksofagethehipisimmature,thereforescreeningexamshouldtakeplaceafter4
weeksandcanbeperformeduntil46months.Xrayexam:canonlydetectindirectsignsofhipdysplasiauntiltheappearanceoftheossificationcentersofthe
femoralhead.
Batteredchild,childabuse,shakenbabysyndrome,nonaccidentalinjury.Theseareallsynonymsdescribingthesyndromeofchildabuse(usuallyofnewborns
andinfants).Atmanytimesonlytheradiologistcanidentifythesecases.Therearesomecharacteristicinjuriesthatarenotinrelationwiththestorytheparentstell.
Fracturesofmultiplenumbers,orinvarioushealingstagesareindicativeofchildabuse.Complexskullfracturesarerareinsimplecasesoffalling.Themost
characteristicsingsaremetaphysealorcornerfracturesonthemetaphisesofthetubularbones.
Violentshakingcausesribfracturesandthetoandfromotionoftheheadleadstosubduralhematomas,hypoxiedematouscontusion.Xrayexamination:chest,
bidirectionalskull,vertebralandlimbradiographsarenecessary.USexamination:bothcranialandabdominalUSareperformedininfants.CTexaminationcanbe
requirediftheabdominalorthevertebralinjuriesaresevere.MRIisunavoidableifneurologicsymptomspersist.

43.ComparisonRadiographoftheknees.Onthedistal
lateralepiphysisoftherightfemurcornerfractureis
seen,lyticarea,periostealreaction.Bothproximaltibia,
onthevisiblepartofthepictureshowperiosteal
reaction.Batteredchild.

Summary

1.ALARAAsLowAsReasonablyAchievable,atermfortheuseofaslowradiationdoseaspossible.Itisafundamentalandprimarypointofviewinpediatric

radiology.
2.DiseasesofthechestcanmostcommonlybediagnosedwithXray,andcomplementaryUSexaminations.CT/MRIisrarelynecessary.
3.Airintheimagingofgastrointestinaldevelopmentaldiseasecanoftenbeusedasanegativecontrastmaterialonplainabdominalxrays,andissufficientfor
diagnosis.
4.TheinvestigationoftheGItractofthenewbornsiscarriedoutbylowosmolality,absorbablecontrastmaterials.USexaminationsareimportantpartofthe
diagnostictoolkit.
5.US,mictioncystourethrography,nuclearmedicineandrarelyMRIareneededinthediagnosticsofurinarytractdisorders.
6.CranialandvertebralUSexaminationshavesomelimitations,butareusefuldiagnosticmethodswhilethefontanellasandthevertebralarchareopen.IftheUS
examinationisnotsatisfactorytheCNSshouldbeexaminedwithMRI.