Heparin and the risk of intraventricular hemorrhage in premature infants

OBJECTIVE

This study was carried out to determine whether the routine use of low-dose heparin in umbilical catheter infusates increases the risk of intraventricular hemorrhage or alters the coagulation profile in premature infants.

METHODS

In a randomized, blinded trial, 113 infants born at less than 31 weeks' gestation were assigned to receive, in their umbilical catheter infusate, either 1 unit of heparin per milliliter (n = 55) or no heparin (n = 58). Prothrombin time, activated partial thromboplastin time, fibrinogen concentration, and antithrombin III activity levels were determined at the start and the completion of the study. Cranial ultrasonography was performed during the first week of life.

RESULTS

There was no difference in the incidence of intraventricular hemorrhage between the heparin and no heparin groups, 35.8% and 31.5%, respectively (p = 0.6). Similarly, no difference was detected in the incidence of severe intraventricular hemorrhage (grades III/IV). Prothrombin time, activated partial thromboplastin time, and fibrinogen levels were not significantly different between the two groups. However, the use of heparin was associated with a lower antithrombin III activity level. Antenatal indomethacin use was associated with a 2.9 increased risk of intraventricular hemorrhage (95% confidence interval, 1.15 to 7.17).

CONCLUSION

A low dose of heparin added to umbilical catheter infusates does not increase the incidence or severity of intraventricular hemorrhage or significantly alter the coagulation profile in premature infants.

Spontaneous resolution of an asymptomatic arachnoid cyst

The authors describe the spontaneous resolution of an intracranial arachnoid cyst. The asymptomatic cyst was incidentally diagnosed at 4 years of age. Resolution of the cyst was noted 7 years later without any history or evidence of trauma.

MR imaging of symptomatic neurocutaneous melanosis in children

Neurocutaneous melanosis is a syndrome consisting of cutaneous nevi and melanocytosis of the leptomeninges. Over a 5-year period (1989-1994) we evaluated with MR imaging the central nervous system of five children with a confirmed histologic diagnosis of neurocutaneous melanosis. The children ranged in age from 7 to 10 years and consisted of two girls and three boys. They all had multiple pigmented skin lesions (cutaneous nevi) and presented with seizures, signs of raised intracranial pressure, cranial nerve palsies and/or myelopathy. The MR studies were performed with T1-weighted, T2-weighted and T1-weighted post-gadolinium images of the brain in addition to T1-weighted post-gadolinium images of the entire spine. The MR findings in all the children consisted of marked, diffuse enhancement of thickened leptomeninges surrounding the brain and spinal cord which was only demonstrated on the post-gadolinium T1-weighted images and mild to moderate hydrocephalus. We present our MR findings and compare these findings with other imaging findings in the literature. Our findings represent part of a spectrum of imaging abnormalities seen in patients with neurocutaneous melanosis.

Persistent respiratory failure due to low cervical cord infarction in newborn babies

Perinatal infarction of the spinal cord is described in two premature babies who survived for several months. In both cases, there was bilateral, multisegmental infarction at the lower cervicothoracic arterial zone (inferior cervical sector), predominantly within the territory of the anterior spinal artery. Clinically, both infants had acute respiratory failure, diaphragmatic respiration, intercostal paralysis, bell-shaped deformity of the thorax, and bilateral arm paresis. Intubation and ventilator support were required for weeks. Eventual extubation was followed by recurrent respiratory failure, atelectasis, and pneumonia. At the level of the infarction, multiple, scattered scars were found in central, perimedullary, and intramedullary arteries, but not in their parent vessels. The etiology of the angiopathy was not determined. These cases demonstrate that discrete arterial infarction of the cord can occur in premature babies, and that such a lesion should be considered in the differential diagnosis of neonatal respiratory failure.

Single forebrain ventricle without prosencephaly: agenesis of the corpus callosum with dehiscent fornices

Coalescence of the cerebral ventricles with formation of a single forebrain ventricle is described in an unusual case of agenesis of the corpus callosum with dehiscent fornices and severe hydrocephalus. The cerebral hemispheres were fully cleaved. The detached fornices were widely separated from the thalami. The membrana tectoria was retroverted over the midbrain and cerebellum, where it joined the fornices and merged with a curved membranous ependymal dome which, at a great distance, circumvented the thalami as it extended toward the anterior commissure. Other anomalies included arhinencephaly, multiple subependymal heterotopias, and Dandy-Walker malformation. Similar malformations have been described as interhemispheric cysts, as (holo)prosencephaly, or as "midline telencephalic dysgenesis." The basic features of prosencephaly and agenesis of the corpus callosum are reviewed and compared to the present case.

MR and CT imaging patterns in post-varicella encephalitis

The aim of the investigation was to determine the patterns of cerebral involvement on computed tomography (CT) and magnetic resonance (MR) imaging in post-varicella encephalitis. Four children between the ages of 2 and 11 years presented over a 5-year period with a diagnosis of post-varicella encephalitis. Their imaging studies and clinical data were reviewed retrospectively. The medical histories of all four children were noncontributory except for recent bouts of chickenpox 1 week to 3 months prior to hospitalization. Three children presented with parkinsonian manifestations. Bilateral, symmetric hypodense, nonenhancing basal ganglia lesions were found on CT. These areas showed nonenhancing low signal intensity on T1-weighted images and high signal intensity on T2-weighted images on MR. One child presented with diffuse, multiple gray and white matter lesions of similar imaging characteristics; some lesions, however, did enhance. This child had no gait disturbances. Post-varicella encephalitis can produce two patterns of dramatic CT and MR findings. With an appropriate history and clinical findings, varicella as a cause of bilateral basal ganglia or diffuse cerebral lesions can be differentiated from other possible etiologies which include trauma, anoxia, metabolic disorders and demyelinating diseases.

Three-dimensional computed tomography imaging in the evaluation of craniofacial abnormalities

A retrospective study was undertaken to assess the value of three-dimensional computed tomography (3-D CT) in evaluating craniofacial abnormalities. Over a 2-year period, 145 children evaluated with routine two-dimensional (2-D) CT had 3-D CT reformatted images assessing a variety of anomalies including craniosynostosis, midface clefts, trauma, and craniofacial syndromes. There were 62 females and 83 males ranging in age from 1 month to 17 years (median: 5 months). Both soft-tissue and bone algorithms were used. In all 145 cases, the 3-D CT images confirmed or provided additional information of depth perception, contours, volumes, and extent of an abnormality. This was especially important and useful in the settings of complex anomalies and preoperative planning. We concluded that 3-D CT reconstructed images in conjunction with routine 2-D CT should be an integral part of the examination in evaluating craniofacial abnormalities.

Intraspinal Wilms' tumor metastases

BACKGROUND

Intraspinal Wilms' tumor metastasis is rare, and is associated with a high mortality rate.

METHODS

The authors reviewed the clinical course of two patients with Wilms' tumor in whom extradural metastasis developed. In addition, a review of the literature and of patients entered in the National Wilms' Tumor Studies was performed to determine the clinical presentation, treatment, and outcome of other patients with Wilms' tumor with intraspinal metastases.

RESULTS

Both of the patients initially had abdominal pain without neurologic deficits. Despite therapy, paraplegia secondary to cord compression from recurrent epidural metastases developed in one patient, although a third remission has been achieved with further chemotherapy. the second patient remains in disease-free remission 25+ months after surgical resection of the extradural spinal tumor, adjuvant chemotherapy and radiation therapy, and autologous bone marrow transplantation. Review of the literature and of the patients entered in the National Wilms' Tumor Studies revealed an additional 27 patients with Wilms' tumor with this pattern of metastasis. Only four were disease-free at the time of this report.

CONCLUSIONS

The authors' experience stresses the importance of early recognition and treatment of this complication of Wilms' tumor and demonstrates that intensive multimodality therapy can result in long-term disease-free remission.

MR of pediatric intracranial meningiomas

PURPOSE

To assess MR and pathologic characteristics of childhood intracranial meningiomas, comparing the radiographic findings with those observed in adult intracranial meningiomas.

METHODS

Clinical records, MR and CT scans, and histology of eight children with intracranial meningiomas presenting for a period of 7.5 years were retrospectively reviewed.

RESULTS

Boys equaled girls but predominated from ages 4 to 11 years. The ages ranged from 4 to 18 years. Two patients had radiation-induced meningiomas. Two children had multiple lesions; neither had neurofibromatosis. All solitary lesions were supratentorial. Other characteristics included: dural-based attachment (n = 6); large size (> 5 cm) (n = 4); cystic components (n = 3); and intraventricular location (n = 1). Histologic subtypes were: meningothelial (n = 4); transitional (n = 3); and fibroblastic (n = 1). Preoperative diagnoses of meningiomas were made in six cases based on overall imaging characteristics.

CONCLUSIONS

Diagnosis of childhood intracranial meningiomas does not differ from that of adults radiographically, with the exception of larger tumor sizes.

The role of bone scintigraphy in detecting child abuse

This review of diagnostic imaging in cases of suspected child abuse characterizes the significant differences between bone scintigraphy and x-ray evaluation, describes the advantages and disadvantages of each modality, postulates on the specific mechanisms of injury that produce the characteristic scintigraphic findings, and emphasizes the influences that scintigraphic studies have on the medical, social, and legal aspects of child abuse. The major advantages of bone scintigraphy are its increased sensitivity (25% to 50%) in detecting evidence of soft tissue as well as bone trauma in child abuse. Furthermore, it is postulated that the specific mechanisms of inflicting the trauma relate to the patient's size and are characterized by bone scintigraphy. During fits of anger or frustration, the perpetrator of child abuse grasps the small infant or child by the thorax during the shaking activity. This produces characteristic rib injuries. The older and heavier child is more likely to be grabbed by the extremities, which produces periosteal injuries manifested as characteristic abnormal localizations in the diaphyses of the extremities. The roentgenograms of these injuries are frequently normal. The importance of bone scintigraphy is its complementary nature in defining and characterizing the extent and severity of trauma from child abuse. Such findings have direct bearing on the medical, social, and legal outcomes for the abused child. The quality of scintigraphic imaging is important, requiring the use of magnification techniques in the infant. The interpretation of the scintigraphic images depends on an understanding of the mechanisms by which the radionuclide localizes in bone. The same traumatic incident can lead to decreased, normal, or increased localization at the trauma site. Radionuclide scintigraphy is a complementary rather than competitive imaging modality to X-ray evaluation in the diagnosis and management of physical child abuse.

Carboplatin-induced regression of an optic pathway tumor in a child with neurofibromatosis

Optic pathway tumors are common in children with neurofibromatosis-1 (NF-1). The optimal management of these tumors is unknown, particularly when the optic chiasm and other brain structures are involved. We report the dramatic response to carboplatin in a 10-year-old girl with NF-1 and a progressive optic pathway tumor. Tumor shrinkage was accompanied by striking improvement in visual fields, return of color discrimination, and marked improvement in visual acuity. No significant toxicity was observed. One year following completion of chemotherapy the glioma remains as small or smaller than it was at the conclusion of therapy, and there has been no deterioration of vision. Carboplatin is a promising agent for the treatment of optic pathway tumors in children with NF-1.

The radiological evaluation of the child with a myelomeningocele

Seven hundred fifty-five children with myelomeningoceles were evaluated radiologically at the Children's Memorial Hospital in Chicago. From our material, we propose a diagnostic radiologic model to accurately evaluate the neurological problems in the myelomeningocele child. This model is based on the clinical symptoms in these children and the radiologic modalities of magnetic resonance imaging (MRI), computed tomography (CT), ultrasound, myelography, and plain radiographs. We found MRI to be the best modality to evaluate the posterior fossa and total spine. Computed tomography and ultrasound are used to evaluate ventricular size. At times MRI may not adequately diagnose subtle cases of tethering of the spinal cord, cord infarction, arachnoid cysts, or diastematomyelia. In these cases, further evaluation may be necessary with real time ultrasound to look at cord pulsations and water soluble myelography with follow through CT to differentiate cord infarction, arachnoid cyst, localized hydromyelia, or diastematomyelia. If MRI is not adequate to completely visualize the cord because of the severe nature of the scoliosis, then water soluble myelography with CT is indicated.

Radiographic manifestations of congenital anomalies of the spine

Although the foregoing review of embryologic development and congenital anomalies of the spine in infants and children is necessarily brief, the most commonly encountered abnormalities have been reviewed, and when possible, an attempt has been made to cite the stage of embryologic development at which the various abnormalities originate. As noted, congenital abnormalities of the spine are relatively uncommon but may be of profound clinical significance. During the past decade, the most significant developments in the diagnosis and treatment of these abnormalities have been ultrasonography, CT scanning, and MR imaging. In the neonate, the spinal cord and neural outflow can be evaluated by ultrasonography until the osseous elements begin to fuse. Thereafter, MR imaging is the procedure of choice because it permits evaluation of the spine and spinal cord in all planes of imaging and provides detailed evaluation of the effect of osseous abnormalities on neural structures. Finally, plain radiographs of the spine for evaluation of neonates who have any of a spectrum of sacral dimples are rarely helpful, and in the presence of significant cutaneous or subcutaneous abnormalities, ultrasonography is the preferred modality for evaluation.

The MR evaluation of pachygyria and associated syndromes

A retrospective study of 40 children with some form of pachygyria was performed at the Children's Memorial Hospital in Chicago. All 40 children had MR brain scans. We analyzed the MR findings, and correlated these findings with the clinical symptoms and course in all the children. We have autopsy findings in 15% these children. Based on our clinical, MR and autopsy findings, in conjunction with the medical literature, we found the following: (1) Pachygyria can occur as an isolated entity without an association with lissencephaly. The MR findings in these children consisted of a brain that demonstrated normal opercularization with either focal or diffuse areas of pachygyria without areas of agyria. These children live longer and have less severity of symptoms than the children with lissencephaly. (2) The MR findings in children with lissencephaly consisted of a brain that demonstrated abnormal opercularization with areas of total agyria or areas of agyria with pachygyria. (3) The MR findings in 25% of our children with polymicrogyria simulated pachygyria. The MR findings of the brain in these children consisted of a 'nubby' appearance to the outer surface of these abnormal gyri which resembled pachygyria but on histologic exam was polymicrogyria.

Maxillary deformation in unilateral coronal synostosis

Distinct osseous structural differences exist between patients with unilateral coronal synostosis and those with "deformational plagiocephaly." Patients with unilateral coronal synostosis exhibit significant anterior displacement of the infraorbital rim relative to the ipsilateral frontal bone and contralateral infraorbital rim (p less than 0.005). Patients with deformational plagiocephaly are noted to have retrusion of the frontal bone and infraorbital rim on the involved side. The observed differences, documented utilizing computerized tomography, are easily appreciated on clinical examination, facilitating rapid distinction between these two entities.

Bone metastases of medulloblastoma in childhood; correlation with flow cytometric DNA analysis

Thirty children with medulloblastoma who were treated between 1980 and 1986 are presented. Flow cytometric DNA analysis using formalin-fixed and paraffin-embedded tissues showed that 15 were DNA aneuploid, 13 diploid and 2 tetraploid. After homogeneous treatment with a combination of radical resection and radiation therapy, patients with DNA aneuploid medulloblastoma showed significantly better outcome (p = 0.003). Among these 30 patients, 6 (20%) had bone metastases of medulloblastoma during a minimum of 2-year follow-up period. DNA ploidy of these patients was diploid in 5 and aneuploid in 1. Incidence of bone metastases appears to correlate with DNA ploidy (p = 0.046). At the time of discovery of bone metastases, 4 had no demonstrable recurrence in the central nervous system (CNS). Radionuclide bone scan was more sensitive in disclosing these lesions, while only one patient had positive results of bone marrow aspirates/biopsy. Three patients were treated with chemotherapy, two had a combination of regional irradiation and chemotherapy and one refused treatment. All treated bone metastases in 5 patients responded clinically and radiographically, but only one patient is alive 66 months after therapy. Four patients died due to either CNS recurrence of septic complication of chemotherapy. Early detection of bone metastases by use of frequent bone scans is important. Patients with diploid medulloblastoma should be treated with adjuvant chemotherapy in order to prevent recurrences and metastases.

The clinical and radiological evaluation of absence of the corpus callosum

A retrospective and prospective analysis of children with a diagnosis of complete absence of the corpus callosum (ACC) at the Children's Memorial Hospital in Chicago over a 5-year period was performed. The diagnosis was based on the computed tomography (CT) and/or magnetic resonance (MR) images. From this material, 105 children with a diagnosis of ACC were analyzed on the basis of clinical symptomatology and radiological studies (CT, MR and ultrasound). Eighty-three percent of our children were symptomatic. The most common symptoms and signs were macrocephaly with hydrocephalus and seizures. MR was the best radiological imaging modality for evaluating children with ACC and associated brain anomalies. The most common associated brain anomalies with ACC in decreasing frequency in our children were: interhemispheric cyst with hydrocephalus, Dandy-Walker malformation, migrational disorders, absence of the inferior vermis, cephaloceles and lipoma of the interhemispheric fissure.

Orbital roof fractures in the pediatric population

Twenty-three patients aged 3.3 +/- 1.6 years (mean +/- SD) presented between January of 1984 and September of 1987 with fronto-orbital trauma resulting in fractures of one (N = 20) or both (N = 3) orbital roofs. All patients had computed tomography (CT) with axial and coronal sections that revealed three fracture patterns of the orbital roof (nondisplaced, superiorly displaced, and inferiorly displaced fractures). Orbital dystopia was exhibited in 35 percent (N = 8) of the patients. Exophthalmos was noted in 61 percent (N = 14) of the patients. Only 30 percent of the patients (N = 7) sustained associated maxillofacial fractures. Eight percent of fractures exhibited orbital encephaloceles. All patients lacked frontal sinus pneumatization. The majority of children with orbital roof fractures do not exhibit concomitant facial fractures. CT utilizing both axial and coronal sections is valuable in defining the extent and pattern of the fracture as well as in identifying associated neurologic injuries. Large, displaced orbital roof fractures, which occurred in 3 of 13 patients with displaced fractures in our series, should undergo early reduction to avoid late development of encephalocele.

Orbital roof fractures in childhood

The authors documented 36 orbital roof fractures in 32 children over a 5-year period. With the aid of computed tomography (CT), 16 fractures were classified as isolated and 20 were found to be associated with more extensive damage to the skull. Isolated fractures typically occurred in younger children (mean age, 2.8 years) after relatively minor trauma, most often a fall from a height of less than 10 feet. Birth trauma was the cause in one case. Three fourths of the isolated fractures were linear; with extensive trauma, the orbital roof was usually comminuted. Upper eyelid hematoma characteristically developed hours after the traumatic event. There were no significant chronic disturbances of vision, motility, or lid function. Acute neurologic concerns were common, and two patients died, but full recovery was otherwise the rule. In two cases, late development of ocular pulsation led to CT demonstration of encephaloceles. Both of these children had comminuted roof fractures with displacement of bone fragments into the orbit. The authors conclude that fracture of the orbital roof is a common but frequently overlooked occurrence in childhood. Anatomic factors may account for differences in the effect of frontal impact at different ages.

Multiple meningiomas in a child

We report the case of a 4-year, 5-month-old boy, who had unusual multiple meningiomas occurring simultaneously in the intracranial, intraorbital, and spinal spaces. All lesions were surgically excised and histologically proved. This is the youngest patient with multiple meningiomas without history of neurofibromatosis reported in the literature.

Neonatal brain tumors: CT and MR findings

Twelve neonatal brain tumors, presenting within 60 days of birth, constituted 3.3% of pediatric brain tumors. Three-fourths were supratentorial. Two-thirds were benign. Forty-two percent were choroid plexus papilloma. Twenty-five percent were teratoma. Eight percent each were hypothalamic glioma, gliosarcoma, medulloblastoma, and primitive neuroectodermal tumor. Clinical symptoms were nonspecific. Signs of herniation were absent in all 12 patients. Forty-two percent of these patients died 1 day to 8 months after diagnosis. Ultrasound, CT, and magnetic resonance have all proved useful for displaying these lesions suitably for surgery.

Developing a clinical algorithm for early management of cervical spine injury in child trauma victims

To define a subset of injured children for whom emergency cervical spine radiography may be unnecessary, we performed a retrospective chart and radiologic review. Two entry methods were used: All injured children, from birth through 16 years, who had received cervical spine radiographs at The Children's Memorial Hospital from September 1983, to September 1984, were included. All patients from birth to 16 years with proven or suspected cases of cervical spine injury who had received cervical spine radiographs and who had been treated at either the Children's Memorial Hospital or the Northwestern University Spine Trauma Unit during period 1974 to 1984 also were included. Each child's chart was reviewed, and 84 clinical variables were recorded. All radiographs were reviewed by a pediatric neuroradiologist. Of 206 children studied, 59 had cervical spine injuries. A clinical algorithm was derived using the following eight variables: neck pain; neck tenderness; limitation of neck mobility; history of trauma to the neck; and abnormalities of reflexes, strength, sensation, or mental status. The following decision rule was selected: Positive findings in any of these eight variables mandates cervical spine radiography. This algorithm correctly identified 58 of 59 children with cervical spine injury, yielding a sensitivity of 98% and specificity of 54%. Cervical spine radiographs could have been avoided in 79 children (38% of the entire sample). This algorithm performed better than did models derived from logistic regression analysis of the same data. Validation trials are required prior to the implementation of this or other clinical decision algorithms in practice.

Real-time sonographic display of caudal spinal anomalies

Real-time computerized ultrasonography with 3.5 and 5.0 MHz sector and linear array transducers (Acuson) depicts spinal anatomy and pathology more clearly than was possible with previous ultrasonic equipment. Split screen (dual image) techniques display increased lengths of spine in a single image. Articulated arm, B-mode sonography remains useful for older patients in whom the pathology lies far from the transducer and in a few post-operative patients in whom dense scar frustrates real-time examination. Sonography is a very useful screening tool for subcutaneous pathology, meningoceles and lipomas, but, thus far, has failed to demonstrate consistently the presence of hydromyelia, intracanalicular (epi)dermoid tumors and dermal sinus stalks ascending toward conus medullaris.

Chronic cerebral herniation in shunted Dandy-Walker malformation

A review of serial computed tomography (CT) scans of 25 patients with the Dandy-Walker malformation revealed six patients with chronic downward transincisural herniation of the cerebrum after shunt decompression of the posterior fossa cyst or malfunction of a lateral ventricular drainage catheter, or both. Chronic cerebral herniation was detected postmortem in a seventh patient with the Dandy-Walker malformation. The CT findings and autopsy appearance of this previously undescribed feature of shunted Dandy-Walker malformation are illustrated.

Shard-like calcifications in retroperitoneal teratomas

Retroperitoneal teratomas can have characteristic roentgenographic findings. Three children with that neoplasm had roentgenographic assessments of the tumor which revealed similar "shard-like" calcifications. The effect of the tumor on the kidneys produced hypertension in all the patients which abated post-operatively. Extensive imaging evaluations in similar patients seems unnecessary since the findings are virtually pathognomonic. Only a single urinary tract study and plain film investigation of the abdomen are advised prior to expeditious surgery.

Radiation exposure due to scatter in neonatal radiographic procedures

Radiation exposure due to scatter from radiographic examinations in the neonatal nursery depends on a number of parameters, such as beam kilovoltage, beam size, and distance from the infant being radiographed. These exposures are much less than those encountered in adult portable radiography. It is shown that, if reasonable precautions are taken, exposure to personnel in the nursery should be well within permissible limits.

Craniocerebral trauma in the child abuse syndrome: radiological observations

Experience with craniocerebral trauma in 712 physically abused children is reviewed. Ninety-three (13%) had evidence of head trauma (cranial and/or intracranial). Seventy-seven of these patients had computed tomography (CT) of the head, and 47 had CT evidence of intracranial injury. Extracerebral fluid collections, predominantly convexity subdural hemorrhage, were the most common acute intracranial lesions. Concurrent intracranial and skeletal trauma (cranial and/or extracranial) was present in 33 of the 47 patients (70%) with intracranial injury. A high incidence of skull fractures (45%) in those children with intracranial lesions suggest a significant role for impact head injuries ("battering") in the pathogenesis of craniocerebral trauma in the child abuse syndrome. Greater emphasis on CT examination in evaluation of the abuse infant and child is recommended.

Cavitation in acute histoplasmosis

Cavitary lung lesions in histoplasmosis are usually associated with the chronic form of the disease. This report describes a ten-year-old boy with the clinical and serologic pattern of acute Histoplasma capsulatum infection who had multiple cavitary lesions.

The abused child: a radiological reappraisal

Radiological findings in 563 abused infants and children who were studied retrospectively emphasize the limitations of diagnostic imaging, specifically radiographic examination of the skeleton. Skeletal trauma was detected in less than one-third of all patients and was uncommon beyond two years of age. Fractures were rarely present without clinical evidence of physical abuse. Radiographic features considered specific for child abuse (epiphyseal-metaphyseal, rib fractures) or highly suggestive (occult, multiple/repetitive fractures) were distinctly infrequent and limited to infancy. A more efficacious approach to radiological evaluation based on clinical presentation is offered.

Uriniferous perirenal pseudocyst in a neonate with primary obstructive megaureter

The case of a newborn infant with a high-grade ureterovesical junction obstruction--a primary obstructive megaureter--who presented with a perirenal pseudocyst (urinoma) is discussed. Radionuclide studies allowed recognition of this collection and led to the discovery of the ureteral obstruction. The rarity of urinomas in neonates and the scintigraphic appearance of urinomas are emphasized.

Chlamydia pneumonia in infants: radiography in 125 cases

Chlamydia trachomatis was recently discovered to be the causative organism in a distinctive afebrile pneumonia occurring in infants under 6 months of age. Experience with the first 125 cases seen at this hospital during a 3 1/2 year period is reported. Chest radiographs were reviewed of 2,273 infants in this age group with signs of lower respiratory tract infection. The first group comprised 148 patients admitted to the hospital. Chlamydia pneumonia was diagnosed in 41 cases. The second group of 2,125 infants was first seen in the outpatient department where 84 additional cases were detected. From this experience it was concluded that, although there are no radiographic findings specific for Chlamydia pneumonia, a combination of the clinical and radiographic findings strongly suggests the diagnosis before cultures and serum antibody titers are available. Important clinical features include age of onset at 2-14 weeks of age, cough, lack of fever, and elevated serum immunoglobulins. Most chest films show bilateral hyperexpansion and diffuse infiltrates with a variety of radiographic patterns including interstitial, reticular nodular, atelectasis, coalescence, and bronchopneumonia. Pleural effusion and lobar consolidation are not seen. The radiographic changes often suggest a more serious illness than that observed clinically. Radiographic features are described in detail.

Gallium scan as a prognostic indicator in neuroblastoma

Gallium-67 scan results were correlated with the long-term clinical course in ten children with neuroblastoma. The four patients whose primary tumor did not accumulate gallium have exhibited a significantly better survival time (mean duration 68.2 months) as compared to the six patients with gallium-positive tumors (mean duration 16.6 months, P < 0.001). This difference in survival was not explainable on the basis of accepted prognostic indicators, such as age of patient or stage of disease at initial diagnosis. These results indicate that gallium uptake may be a useful prognostic indicator in children with neuroblastoma, independent of other variables.

Neonatal intestinal opacification secondary to transplacental passage of urographic contrast medium

Neonatal intestinal opacification in five infants (one set each of triplets and twins) after maternal excretory urography is described, and mechanisms leading to this phenomenon are discussed. Transplacental passage of urographic contrast medium with subsequent excretion by the fetal kidneys and possibly liver and small bowel seems to explain the radiographic appearance. Although the contrast medium probably does not harm the fetus, it should be distinguished from other more sinister causes of colonic opacification in the neonate.