Presented by Zarna Patel, MD (PGY2)
Clinical Questions:
1) Osteomyelitis in the ribs?! Seems unlikely…
2) Early diagnosis and appropriate treatment is key! MRI is standard choice but it takes so long and delays care.
3) There must be a better way…Could US be a better modality to diagnose osteomyelitis in the ribs? Continue reading
Zuccoli G, et al. Redefining the Guillain-Barré spectrum in children: neuroimaging findings of cranial nerve involvement. AJNR Am J Neuroradiol. 2011 Apr;32(4):639-42.
“GBS and its MFS variant are acute polyneuropathies that are considered to represent a continuum rather than distinct entities, due to the overlap in their clinical features. Enhancement of the CE roots represents the neuroradiologic hallmark of GBS, while findings of neuroimaging studies in MFS are usually unremarkable. Our purpose was to evaluate the MR imaging findings of polyneuropathy in 17 children affected by GBS and its MFS variant. Fourteen of our 17 patients demonstrated CE enhancement, with predominant involvement of the anterior roots. Of 6 patients who underwent MR imaging of the brain, 5 had cranial nerve involvement. In children affected by GBS-MFS, involvement of the CE roots may be considered part of a more extensive autoimmune neuropathy, as demonstrated by enhancement of cranial nerves. Brain MR imaging should be considered in the routine evaluation in pediatric patients with GBS-MFS for the evaluation of the cranial nerves.”
Mackay MT, et al. Brain attacks and stroke in children. J Paediatr Child Health. 2016 Feb;52(2):158-63.
Emergency physicians are often the first point of contact in children presenting with acute neurological disorders. Differentiating serious disorders, such as stroke, from benign disorders, such as migraine, can be challenging. Clinical assessment influences decision-making, in particular the need for emergent neuroimaging to confirm diagnosis. This review describes the spectrum of disorders causing ‘brain attack’ symptoms, or acute onset focal neurological dysfunction, with particular emphasis on childhood stroke, because early recognition is essential to improve access to thrombolytic treatments, which have improved outcomes in adults. Clues to diagnosis of specific conditions are discussed. Symptoms and signs, which discriminate stroke from mimics, are described, highlighting differences to adults. Haemorrhagic and ischaemic stroke have different presenting features, which influence choice of the most appropriate imaging modality to maximise diagnostic accuracy. Improvements in the care of children with brain attacks require coordinated approaches and system improvements similar to those developed in adults.
Mallick AA, et al. Diagnostic delays in paediatric stroke. J Neurol Neurosurg Psychiatry. 2015 Aug;86(8):917-21.
The diagnosis of AIS in children is delayed at every stage of the pathway but most profoundly when the first neuroimaging is CT scanning, which is non-diagnostic. MRI should be the initial imaging modality of choice in any suspected case of childhood AIS.
Bajaj M, Mody S, Natarajan G. Clinical and neuroimaging findings in neonatal
herpes simplex virus infection. J Pediatr. 2014 Aug;165(2):404-407.e1.
In a retrospective review of infants with neonatal herpes simplex virus disease (n=29), we found bilateral multilobar (n=8), pontine (n=3), thalamic (n=6), and internal capsule and corticospinal tract (n=5) involvement on magnetic resonance imaging (MRI). Diffusion-weighted imaging (n=6) performed early revealed additional involvement than detected by conventional MRI. Neurodevelopmental sequelae were correlated with MRI abnormalities. Our findings demonstrate that MRI, including diffusion-weighted imaging, is a valuable prognostic adjunct in neonatal herpes simplex virus disease.
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Hafezi W, Hoerr V. In vivo visualization of encephalitic lesions in herpes
simplex virus type 1 (HSV-1) infected mice by magnetic resonance imaging (MRI). Methods Mol Biol. 2013;1064:253-65.
Herpes simplex encephalitis (HSE) is one of the most severe viral infections affecting the temporal lobes of the brain. Despite the improvements in diagnosis and antiviral drug treatment, one third of all patients fail to respond to therapy or subsequently suffer neurological relapse and develop long term neurological damage. Magnetic resonance imaging (MRI) is among the appropriate noninvasive tools for early diagnosis of viral central nervous system (CNS) infections. In this chapter we introduce a mouse model for HSE and describe a MRI protocol to characterize the pathogenesis of HSE over time.
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“Conventional and advanced neuroimaging have become central to the diagnosis of infectious diseases of the pediatric central nervous system. Imaging modalities used by (pediatric) neuroradiologists include cranial ultrasound, computed tomography, and magnetic resonance imaging, including advanced techniques such as diffusion weighted or tensor imaging, perfusion weighted imaging, susceptibility weighted imaging, and (1) H magnetic resonance spectroscopy. In this first of a two part review, imaging techniques in general and the imaging findings of bacterial infections of the intracranial compartment including epidural empyema, subdural empyema, meningitis, cerebritis, cerebral abscess, and pyogenic intraventricular empyema (ventriculitis) are discussed.”
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“In the second half of this 2-part review, the neuroimaging features of the most common viral, fungal, and parasitic infections of the pediatric central nervous system are discussed. Brief discussions of epidemiology and pathophysiology will be followed by a review of the imaging findings and potential differential considerations.”
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Pediatric intracranial infections. (2012)
“Infection of the central nervous system (CNS) in children is an important entity and early recognition is paramount to avoid long-term brain injury, especially in very young patients. The causal factors are different in children compared with adults and so are the clinical presentations. However, imaging features of CNS infection show similar features to those of adults. This article reviews some of the common types of pediatric infections, starting with the congenital (or in utero) infections followed by bacterial infections of the meninges and brain parenchyma.”
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“Infections of the head and neck vary in their clinical course and outcome because of the diversity of organs and anatomic compartments involved. Imaging plays a central role in delineating the anatomic extent of the disease process, identifying the infection source, and detecting complications. The utility of imaging to differentiate between a solid phlegmonous mass and an abscess cannot be overemphasized. This review briefly describes and pictorially illustrates the typical imaging findings of some important head and neck infections, such as malignant otitis externa, otomastoiditis bacterial and fungal sinusitis, orbital cellulitis, sialadenitis, cervical lymphadenitis, and deep neck space infections.”
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“Neuroimaging plays an important and growing role in the diagnosis and therapeutic management of pediatric brain infections. This article describes the spectrum of imaging findings associated with major pediatric viral and bacterial brain infections, outlining the role of current imaging technology in the differential diagnoses of brain injury, detection of complications and therapy monitoring. MRI is the tool of choice in the evaluation of brain infections and particular attention is devoted to the role of diffusion-weighted imaging and magnetic resonance spectroscopy. This article considers viral and bacterial infection in their different modalities of presentation as congenital, acute and subacute/chronic disease. With regard to congenital infections, the growing role of fetal MRI as a valuable complement to ultrasound in the prenatal assessment of brain damage is emphasized.”
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More PubMed results on imaging of brain infections.
“CT is the imaging method of choice for the paranasal sinuses [20]. Coronal CT imaging gives the best overall anatomic detail of the paranasal sinuses and can be achieved either with prone direct coronal imaging or can be reformatted from thin-slice axial images. Contrast enhancement is not generally needed for routine sinus imaging. Sinus radiographs are inaccurate in a high percentage of patients and have been supplanted by CT imaging [21].
Magnetic resonance imaging (MRI) is currently used for evaluation of sinus disease as a complementary study in cases of aggressive sinus infection with ocular/intracranial complications or in the evaluation of a sinonasal mass. Because of its cost, longer imaging time, and lack of bone detail, it has not been considered the imaging method of choice for routine sinus imaging. Recent public health concerns regarding the dramatic and ever-increasing usage of CT imaging and emphasis on reducing medical radiation exposure may lead to consideration of alternative imaging techniques. One study suggests that MRI-based Lund-Mackay scores did
not show a statistically significant difference compared to CT-based scores in the same patients [26].”
Imaging the paranasal sinuses: where we are and where we are going. (2008)
“As has happened in all facets of neuroimaging, cross-sectional imaging has dramatically changed our approach and understanding of the anatomy and pathology of paranasal sinuses. We have moved away from plain film radiographs to modern high-resolution sinus computerized tomography (CT) and magnetic resonance imaging (MRI) that helps us better depict underlying normal anatomy and evaluate pathology. Recent advances in PET/CT imaging have introduced a physiologic aspect to anatomical imaging and holds promise to better stage and restage head and neck tumors. In this article, we describe the various imaging techniques, concerns, advantages and disadvantages of the individual techniques, and provide an overview of the various pathologies involving the paranasal sinuses.”
“Sinonasal disease is one of the most common clinical head and neck pathologies. The majority of sinonasal pathology is inflammatory with neoplasms comprising approximately 3% of all head and neck tumours. Although sinus tumours are rare, they portend a poor prognosis, often due to advanced disease at diagnosis. Like most neoplasms, early detection improves prognosis, therefore clinicians and radiologists should be aware of features separating tumours from inflammatory sinus disease. This article reviews the anatomy, clinical features, imaging findings, treatment and histopathology of selected sinonasal tumours. Benign neoplasms reviewed include osteoma, inverting papilloma, and juvenile nasal angiofibroma. Malignant neoplasms reviewed include squamous cell carcinoma, the minor salivary gland tumour, adenoid cystic carcinoma, adenocarcinoma, melanoma, lymphoma, and olfactory neuroblastoma (esthesioneuroblastoma).”
“Pediatric sinonasal anatomy changes and develops from birth to adolescence. This article elucidates the normal anatomy and patterns of development in the pediatric population. Issues in pediaric sinusitis include indications for imaging, the nonspecificity of sinus opacification, and the importance of clinical information. Sinonasal physiology is briefly discussed to offer insight into the interpretation of radiographic findings. Cystic fibrosis, polyps, and choanal atresia, representing the spectrum of common pediatric sinonasal inflammatory disorders are illustrated, and the spectrum of orbital and intracranial complications of sinusitis is reviewed.”
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For more PubMed results on sinonasal imaging.
Pediatric Focus 