Congenital diaphragmatic hernia in neonates: variations in umbilical catheter and enteric tube position.

PURPOSE: To evaluate anatomic variations of support apparatus position on radiographs obtained in neonates with congenital diaphragmatic hernia (CDH). MATERIALS AND METHODS: The authors evaluated radiographs obtained in 71 neonates with CDH to determine whether nasogastric tubes, umbilical venous catheters, and umbilical arterial catheters deviated from their expected anatomic course. The relationship between deviation patterns and hernia contents was evaluated. RESULTS: Sixty-eight neonates-54 with left-sided CDH and 14 with right-sided CDH-had a nasogastric tube. The tubes in 21 patients with left-sided CDH had a normal anatomic course at radiography. Nineteen of these patients did not have stomach in the hernia. In 13 patients, the tip of the nasogastric tube was lodged at the esophagogastric junction. In 17 patients, the tube was in the left hemithorax. In all 30 of these patients, the stomach was within the CDH. All nasogastric tubes in the 14 patients with right-sided CDH had leftward deviation. Thirty-seven patients-27 with left-sided CDH and 10 with right-sided CDH-had umbilical venous catheters. The catheters in 12 patients with left-sided CDH had apex leftward convexity. The umbilical venous catheter in eight patients with right-sided CDH had rightward shift; all eight patients had liver herniation. CONCLUSION: The positions of nasogastric tubes and umbilical venous catheters vary in several predictable patterns in neonates with CDH. Knowledge of these variations may be helpful for supporting the diagnosis of CDH in unclear cases and thus avoiding unnecessary apparatus adjustments, and for predicting hernia contents.

Correlation between findings on chest radiography and survival in neonates with congenital diaphragmatic hernia.

OBJECTIVE: Predictors of survival are helpful when deciding on aggressiveness of care of neonates with congenital diaphragmatic hernia and respiratory failure. We evaluated findings on chest radiography as potential predictors of survival in these patients. MATERIALS AND METHODS: Findings on chest radiographs of neonates less than 24 hr old with congenital diaphragmatic hernia were evaluated. Radiographic findings analyzed included percentage of aerated ipsilateral lung, percentage of aerated contralateral lung, mediastinal shift, and hernia contents. Each finding was compared with survival (equated with hospital discharge) using a Mantel-Haenszel chi-square test. Survival was also determined using the total number of poor prognostic findings present in any one patient. RESULTS: In the 73 neonates with congenital diaphragmatic hernia in our study, the overall survival rate was 55%. There were statistically significant relationships between survival rate and percentage of ipsilateral aeration (p = 0.001), percentage of contralateral aeration (p = 0.016), and mediastinal shift (p = 0.026). The survival rate for multiple poor prognostic factors was 0% with four of four factors and 20% with three of four factors (p = 0.001). Survival rate was not influenced by prematurity (p = 0.102), sex (p = 0.104), or side of hernia (p = 0.895). CONCLUSION: Findings on initial chest radiography are helpful in predicting survival in neonates with congenital diaphragmatic hernia.

Traumatic elbow effusions in pediatric patients: are occult fractures the rule?

OBJECTIVE: Elbow joint effusion with no fracture seen on radiographs of pediatric patients after acute trauma has become synonymous with occult fracture. This study evaluates the incidence of occult fractures in such cases as determined by findings on follow-up radiographs. MATERIALS AND METHODS: Initial and follow-up radiographs were reviewed for 54 children (mean age, 7 years) with a history of trauma who had joint effusion but no identifiable fracture on initial radiographs. The presence of periosteal reaction or bony sclerosis on follow-up radiographs was considered to be evidence of occult fracture. Mean time between initial and follow-up radiographs was 18 days (range, 14-50 days). RESULTS: Only nine (17%) of the 54 patients showed evidence of a healing occult fracture on follow-up radiographs. However, we found a statistically significant relationship (p = .001) between persistent joint effusion on follow-up radiographs and occult fracture. Seventy-eight percent of cases with occult fracture, versus 16% of cases without occult fracture, had persistent effusions. CONCLUSION: Joint effusion without visualized fracture on initial radiographs after trauma does not correlate with the presence of occult fracture in most cases (83%). Therefore, joint effusion as revealed by radiography should not be considered synonymous with occult fracture.

Cavitary necrosis complicating pneumonia in children: sequential findings on chest radiography.

OBJECTIVE: The objective of this study was to describe the sequential clinical and radiographic findings of cavitary necrosis complicating pneumonia in childhood. MATERIALS AND METHODS: A study group of 17 children (mean age, 6 years) was identified by reviewing CT examinations of all patients who underwent CT of the chest to evaluate possible complications of pneumonia over a 3-year period. Children included in the study group were those who met the criteria for cavitary necrosis: loss of lung architecture, decreased enhancement, and multiple cavities with thin, nonenhancing walls. In the 17 identified cases, sequential chest radiographs were reviewed for visibility of a lung cavity. Long-term follow-up radiographs were evaluated for persistent abnormalities. RESULTS: Ten of the 17 cases of cavitary necrosis seen on CT showed cavities at some time on radiography: one cavity was visible at the time of diagnosis on CT and nine were visible only later. All three cavities that were predominantly air-filled on CT were revealed by radiography, whereas 50% (7/14) of predominantly fluid-filled cavities were revealed by radiography. Eleven children underwent follow-up radiography more than 40 days after the diagnosis of cavitary necrosis. Radiographs of those 11 children showed clear lungs without pulmonary sequelae. CONCLUSION: In children, cavitary necrosis is associated with severe illness; however, cases usually resolve without surgical intervention, and long-term follow-up radiography shows clear lungs without pulmonary sequelae. Evidence of cavitary necrosis complicating pneumonia is often seen on CT before or in the absence of findings on chest radiography.

The yield of CT of children who have complicated pneumonia and noncontributory chest radiography.

OBJECTIVE: Our purpose was to investigate the usefulness of CT in evaluating children who do not respond appropriately to treatment for pneumonia, when chest radiography is noncontributory. MATERIALS AND METHODS: Fifty-six contrast-enhanced CT scans were compared with radiographs obtained on the same day in children with complicated pneumonia. CT scans were evaluated for clinically significant findings that were not revealed by radiography: lung parenchymal complications (cavitary necrosis, abscess, decreased enhancement, bronchopleural fistula, or cavity suspected on radiography but not seen on CT), pleural complications (loculation, malpositioned chest tube), inaccurate estimation of cause of chest opacity on radiography (pleural versus parenchymal), bronchial obstruction, or pericardial effusion. RESULTS: One hundred ten CT findings, not revealed by radiography, were seen on 56 CT scans (2.0 per CT scan): parenchymal complications (n = 40), pleural complications (n = 37), inaccurate estimation of cause of chest opacity on radiography (n = 20), pericardial effusion (n = 13). All CT scans showed at least one significant finding (100% yield) not seen on radiography. CONCLUSION: In the evaluation of children with complicated pneumonia, CT often reveals clinically significant findings not apparent on radiography.

Pneumonia in children: decreased parenchymal contrast enhancement--CT sign of intense illness and impending cavitary necrosis.

PURPOSE: To determine if computed tomographic (CT) findings of decreased contrast material enhancement are predictive of more intense illness and of the development of cavitary necrosis in children with pneumonia. MATERIALS AND METHODS: Contrast-enhanced CT scans in 44 children with pneumonia who did not respond appropriately to therapy were compared with precontrast CT scans to evaluate enhancement of consolidated lung parenchyma. Enhancement was correlated with admission to the intensive care unit, length of hospital stay, cavitary necrosis in the lung at follow-up CT, and frequency of lung resection. RESULTS: Parenchymal enhancement was decreased in 21 children; pneumonia was enhanced in the other 23 children. Decreased enhancement was associated with increased admission to intensive care (14 of 21 [67%] vs five of 23 [22%] children; P = .0026), increased length of hospital stay (15 vs 10 days; P = .0615), increased frequency of cavitary necrosis at follow-up CT (seven of seven [100%] vs none of three children; P = .0086), and increased frequency of resection (two of 21 [10%] vs none of 23 children). At histopathologic examination, diffuse cavitary necrosis was present in resected lobes in two patients. CONCLUSION: Decreased parenchymal enhancement at CT is a predictor of more intense illness and may herald the development of cavitary necrosis in children with pneumonia.

Subpleural sparing: a CT finding of lung contusion in children.

PURPOSE: To evaluate the presence of subpleural sparing as an aid in differentiation of contusion from other causes of lung opacification in children. MATERIALS AND METHODS: In 29 children, the computed tomographic (CT) features of 40 lung contusions were reviewed for the presence of subpleural sparing. Other CT characteristics of lung contusion such as location, shape, and confluence were also evaluated. The presence of subpleural sparing was also evaluated in cases of atelectasis, pulmonary laceration, and a control group of CT scans obtained in 45 patients with bacterial pneumonia and no history of trauma. RESULTS: Subpleural sparing was seen at CT in 38 (95%) of the lung contusions and none of the cases of atelectasis, laceration, or pneumonia (P = .0001). Lung contusions tended to be posterior (60%), crescentic (50%), or amorphous (45%) and have confluent and nodular components (70%). CONCLUSION: The presence of subpleural sparing on CT scans enables accurate identification of lung contusion and differentiation of contusion from other causes of lung opacification in children after trauma.

CT appearance of parapneumonic effusions in children: findings are not specific for empyema.

OBJECTIVE: Although definitive differentiation of empyema from transudative parapneumonic effusion is based on the analysis of pleural fluid, certain CT findings have been described as highly suggestive of empyema. This study compares the CT findings of parapneumonic effusions with the results of thoracentesis, thoracoscopy, or both to determine whether these CT findings can reliably differentiate empyemas from transudative parapneumonic effusions in children. MATERIALS AND METHODS: CT scans obtained to evaluate pleural or parenchymal complications of pneumonia were reviewed. Parapneumonic effusions were evaluated for the CT findings of pleural enhancement; parietal pleural thickening; thickening, increased attenuation, or both of the extrapleural subcostal fat: and edema of the extracostal chest wall. Each parapneumonic effusion was assigned a CT score on the basis of these CT findings. Individual CT findings and the CT score were correlated with the presence of empyema as determined by thoracentesis or thoracoscopy. RESULTS: Thirty patients were identified as having a parapneumonic pleural effusion revealed on contrast-enhanced CT scans and by pleural fluid analysis. Twenty-one of these parapneumonic effusions met the clinical criteria for empyema, and nine were considered not to be empyemas. Neither any individual CT finding nor the CT score accurately differentiated empyema from transudative parapneumonic effusions (p > .1): pleural enhancement (empyema 100%, transudative effusion 89%), pleural thickening (empyema 57%, transudative effusion 56%), abnormal extrapleural space (empyema 66%, transudative effusion 67%), extracostal chest wall edema (empyema 33%, transudative effusion 56%), and average CT score (empyema 2.5. transudative effusion 2.3). CONCLUSION: CT characteristics of parapneumonic effusions do not allow radiologists to accurately predict empyema. The presence or absence of such CT findings should not influence therapeutic decisions concerning the management of parapneumonic effusions.