Publications by authors named "Siddharth P Jadhav"

29 Publications

  • Page 1 of 1

Accuracy of computed tomography angiography and structured reporting of high-risk morphology in anomalous aortic origin of coronary artery: comparison with surgery.

Pediatr Radiol 2021 Mar 23. Epub 2021 Mar 23.

Texas Center for Pediatric and Congenital Heart Disease, University of Texas Dell Medical School/Dell Children's Medical Center, Austin, TX, USA.

Background: Morphological features including interarterial course, intramural course, high ostial location and slit-like ostium are presumed risk factors for sudden cardiac death in children with anomalous aortic origin of the coronary artery (AAOCA). To facilitate clinical risk stratification, the diagnostic accuracy of CT angiography for individual risk factors in the setting of AAOCA must be established.

Objective: We assessed diagnostic accuracy of standardized CT angiography interpretation for morphological characteristics that might determine risk in children with AAOCA by comparing them to surgical findings.

Materials And Methods: We created a standardized protocol for CT angiography of AAOCA and retrospectively evaluated diagnostic performance in 25 consecutive surgical patients. Relevant morphological variables in AAOCA were assessed by three independent blinded readers, with surgery as the reference standard. We used Cohen kappa coefficients and accuracies to assess agreement between readers and surgical findings, and we calculated intraclass correlation coefficients to compare length of the intramural course.

Results: CT angiography correctly identified AAOCA in all patients. For the three readers, accuracies for detecting ostial stenosis were 84%, 94% and 96%; for high ostial origin, accuracies were 76%, 78% 82%; for intramurality using the peri-coronary fat sign, accuracies were 98%, 96% and 92%; and for intramurality using oval shape of coronary artery, accuracies were 98%, 94% and 92%. The intraclass correlation coefficients (ICCs) for predicting intramural length among the three readers were 0.67, 0.75 and 0.81 using peri-coronary fat, and 0.69, 0.50 and 0.81 using oval shape, respectively.

Conclusion: CT angiography reliably identified AAOCA in all children and detected the presence of intramurality with high accuracy.
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http://dx.doi.org/10.1007/s00247-021-05011-0DOI Listing
March 2021

Pediatric Bassett's ligament: pathology or normal anatomy?

Pediatr Radiol 2021 Feb 17. Epub 2021 Feb 17.

Edward B. Singleton Department of Radiology, Texas Children's Hospital, 6701 Fannin St., Suite 470, Houston, TX, 77030, USA.

Background: Bassett's ligament is an accessory fascicle of the anterior inferior tibiofibular ligament. The prevalence, normal thickness and clinical implications of a thickened ligament have not been described in the pediatric radiology literature.

Objective: The purpose of this study was to determine the prevalence and thickness of Bassett's ligament in pediatric patients with magnetic resonance imaging (MRI) findings of lateral talar osteochondral lesions, medial talar osteochondral lesions and posterior ankle impingement, to compare these measurements with normal MRIs, and to compare the reproducibility of these measurements.

Materials And Methods: This is a retrospective study of pediatric ankle MRIs with four cohorts containing 21 patients each. All MRIs were retrospectively reviewed by a pediatric musculoskeletal radiologist and a pediatric radiology fellow. The prevalence of Bassett's ligament and its axial thickness were obtained for each cohort with repeat measurements for intra-observer and interobserver variability. Average thickness and standard deviation of Bassett's ligament were calculated.

Results: The prevalence of Bassett's ligament and its thickness in each cohort were (mean±standard deviation): lateral osteochondral lesions, 71% (15/21), 1.9±0.5 mm; medial osteochondral lesions, 52% (11/21), 1.4±0.2 mm; posterior impingement, 52% (11/21), 1.3±0.2 mm; and normal ankle examinations, 71% (15/21), 1.5±0.4 mm. The thickness of Bassett's ligament was increased in the lateral talar osteochondral lesion group when compared to normal (P=0.02), while thickness in the medial osteochondral lesion and posterior impingement groups was not significant when compared to normal. The repeat measurements showed no significant difference in intra-observer and interobserver variability.

Conclusion: Bassett's ligament is a normal structure in children. Thickening of Bassett's ligament is seen with lateral osteochondral lesions and may be an indirect sign of anterolateral tibiotalar capsule injury.
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http://dx.doi.org/10.1007/s00247-020-04942-4DOI Listing
February 2021

Arcuate sign-fibular head avulsion fracture and associated injuries in the pediatric and adolescent population.

Emerg Radiol 2021 Feb 10. Epub 2021 Feb 10.

E.B. Singleton Department of Radiology, Texas Children's Hospital, 6701 Fannin Street, Suite 470, Houston, TX, 77030-2399, USA.

Purpose: To describe the first "arcuate sign" case series in the pediatric population, radiologic features of the associated injuries, management, and how they compare with the adult population.

Methods: Retrospective study included patients under 18 years of age with a classic "arcuate sign" on radiographs. Data collected included patient demographics, mechanism of injury, and management. Radiographs and advanced imaging (MRI, CT) were reviewed by two musculoskeletal radiologists in a blinded fashion and findings recorded.

Results: Seven patients (4 males, 3 females) with mean age 15 years (range 14-17 years) were included in the study. All 7 injuries were related to sports, 5/7 (71%) being non-contact injuries. Five patients had MRI done-1 LCL injury, MPFL sprain, and MCL sprain were reported; 3 popliteofibular ligament and popliteus sprains were seen; and 3 bone contusions were present on imaging. None of the patients had meniscus or cruciate ligament tears. One patient had an additional fracture of the lateral tibial plateau at the ilio-tibial band attachment and an associated peroneal nerve injury. Five out of seven (71.4%) were treated non-operatively and were able to return back to activity at a mean of 7.2 weeks from injury. Two out of seven (28.6%) needed operative intervention for the fracture but not arthroscopic repair.

Conclusion: Pediatric patients with a radiographic arcuate sign tend not to have ACL, PCL, or meniscal injuries, and treatment is predominantly non-operative in contrast to literature reported in adults.
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http://dx.doi.org/10.1007/s10140-021-01910-9DOI Listing
February 2021

Role of gated cardiac computed tomographic angiography in the evaluation of postsurgical complications after stage I Norwood procedure and its implications on management: a comparative study with two-dimensional echocardiography.

Pediatr Radiol 2021 Feb 4. Epub 2021 Feb 4.

Edward B. Singleton Department of Radiology, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin St., Suite 470, Houston, TX, 77030, USA.

Background: The Norwood procedure is the first part of a three-stage surgical palliation for patients with functionally single ventricle anatomy. Complications after the stage I operation are not uncommon. Transthoracic echocardiography (TTE) is traditionally the mainstay for evaluation.

Objective: The purpose of our study is to compare gated cardiac computed tomographic angiography (CCTA) with TTE when evaluating for postoperative complications after stage I Norwood procedure and to describe management implications.

Materials And Methods: A retrospective chart review of all patients over a 4-year period who underwent nonelective urgent CCTA for suspected complications related to stage I Norwood procedure was performed. Elective CCTA studies before stage II palliation were excluded. Patient demographics, CCTA and TTE findings, as well as interventions performed, were recorded.

Results: Thirty-four patients were included. The mean age at CCTA was 63 days (range: 4-210 days). All patients had a recent TTE with a mean time interval between TTE and CCTA of 2 days. CCTA detected 56 abnormalities in 30 patients, with 23 directly related to postsurgical complications, including shunt-related complications (10/23, 43%), Damus-Kaye-Stansel anastomotic narrowing (2/23, 9%) and neo-aortic arch/branch vessel abnormalities (11/23, 48%). These complications were managed as follows: surgery (9, 39%), catheter-based intervention (7, 30%), medical (4, 17%) and no change in management (3, 13%). TTE did not detect 8/23 (35%) findings found on CCTA, of which 75% were either managed with surgery (4/8, 50%) or catheter-based intervention (2/8, 25%).

Conclusion: CCTA plays an important role in detecting surgical complications after stage I Norwood procedure and demonstrates additional findings that have direct management implications.
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http://dx.doi.org/10.1007/s00247-021-04966-4DOI Listing
February 2021

Percutaneous ultrasound-guided ganglion fenestration in children: initial results.

Skeletal Radiol 2021 Jun 6;50(6):1169-1175. Epub 2020 Nov 6.

Edward B. Singleton Department of Radiology, Texas Children's Hospital, 6701 Fannin St., Suite 470, Houston, TX, 77030, USA.

Objective: To evaluate our pediatric experience with percutaneous ultrasound-guided fenestration of ganglia (PUGG).

Materials And Methods: Retrospective study of pediatric patients who underwent PUGG from June 2016 to October 2018 at a free-standing tertiary referral academic children's hospital with a minimum of 6 months follow-up. Electronic medical records, picture archiving system, and post-procedural calls were utilized for patient demographics, lesion characteristics, procedure details, and recurrence. The procedure itself consisted of assessment by Child Life, application of topical anesthetic cream, sterile preparation and draping, and intra-procedural ultrasound guidance for local anesthetic instillation, ganglion aspiration, fenestration, and intra-remnant steroid instillation. Post-procedure care included an ice pack, compression dressing for 48 h, and 4 weeks of brace wear and activity restriction.

Results: Forty-five patients met the inclusion criteria, ages 3-18 years, mean 13.5 years, and female to male ratio of 2:1. Ganglion locations consisted of 80% (36/45) in the wrist and 20% (9/45) in other locations (elbow, ankle, and foot). Ninety-eight percent (44/45) of procedures were performed non-sedated, including 20% (9/44) between ages 7 and 11 years. 28.9% (13/45) of ganglia recurred, the earliest at 3 weeks, the latest at 10 months, and an average of 3 months' time. No complication occurred and no patients required post-procedural narcotics or Emergency Department visitation for pain control.

Conclusion: Percutaneous ultrasound-guided fenestration of ganglia (PUGG) is a safe, minimally invasive alternative to surgical excision in the pediatric population, which can be performed without sedation and does not leave a scar.
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http://dx.doi.org/10.1007/s00256-020-03662-yDOI Listing
June 2021

Diagnostic sensitivity and specificity of CT angiography for renal artery stenosis in children.

Pediatr Radiol 2021 Mar 5;51(3):419-426. Epub 2020 Nov 5.

Edward B. Singleton Department of Radiology, Texas Children's Hospital, 6701 Fannin Street, Suite 470, Houston, TX, 77030, USA.

Background: Children with suspected renal artery stenosis (RAS) are screened with renal Doppler ultrasonography or computed tomography (CT) angiography/magnetic resonance (MR) angiography depending on institutional preference. CT angiography produces images with superior resolution, allowing higher quality multiplanar two-dimensional reformats and three-dimensional reconstructions. However, there is a paucity of data in the literature regarding the utility and diagnostic performance of renal CT angiography in pediatric RAS.

Objective: The objective of this study is to retrospectively review our experience with renal CT angiography in the diagnosis of pediatric RAS relative to digital subtraction angiography (DSA) as the reference standard.

Materials And Methods: All patients 0-18 years of age who underwent CT angiography for evaluation of RAS as a cause of hypertension between January 2012 and May 2019 were identified for the study. A total of 131 patients were identified, 23 of whom had DSA correlation.

Results: Twenty-three patients (17 boys, 6 girls) with a mean age of 6 years 3 months (range: 3 months to 14 years 7 months) were included in this study. Of the 59 renal arteries studied by DSA, 22 were abnormal on CT angiography and 20 were abnormal on DSA. Of the 59 renal arteries, CT angiography was true positive in 18 and true negative in 35. The sensitivity and specificity of CT angiography for RAS diagnosis were 90.0% and 89.7%, respectively. CT angiography identified all cases of main RAS.

Conclusion: Renal CT angiography has a high sensitivity and specificity for pediatric RAS diagnosis in patients referred for DSA.
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http://dx.doi.org/10.1007/s00247-020-04852-5DOI Listing
March 2021

E-cigarette or vaping product use-associated lung injury in the pediatric population: imaging features at presentation and short-term follow-up.

Pediatr Radiol 2020 08 3;50(9):1231-1239. Epub 2020 Jun 3.

Edward B. Singleton Department of Radiology, Texas Children's Hospital, Houston, TX, USA.

Background: Cases of e-cigarette or vaping product use-associated lung injury (EVALI) have rapidly reached epidemic proportions, yet there remain limited reports within the literature on the associated imaging findings.

Objective: We describe the most common imaging findings observed on chest computed tomography (CT) and chest radiograph (CXR) at presentation and at short-term follow-up at our major pediatric hospital.

Materials And Methods: A retrospective review of the electronic medical records was performed on all patients with suspected EVALI who were treated at a major pediatric hospital and 11 patients were included for analysis. Two board-certified pediatric radiologists then categorized the CXRs as either normal or abnormal, and further performed a systematic review of the chest CTs for imaging findings in the lungs, pleura and mediastinum. Interrater discordance was reconciled by consensus review.

Results: The 11 patients (9 males:2 females) ranged in age from 14 to 18 years. Gastrointestinal and constitutional symptoms were present in all patients, whereas shortness of breath and cough were reported in 5/11 and 6/11 patients, respectively. The CXR was abnormal in 10/11 patients, whereas all chest CTs were abnormal. The most common CT findings included consolidation, ground-glass opacities, interlobular septal thickening, lymphadenopathy and crazy-paving pattern. Almost all patients demonstrated subpleural sparing, and less than half also demonstrated peribronchovascular sparing. There was complete or near-complete resolution of imaging abnormalities in 5/6 patients with a median follow-up duration of 114 days.

Conclusion: Pulmonary opacities with subpleural and peribronchovascular sparing was a commonly observed pattern of EVALI in the pediatric population at this institution. A CXR may not be sufficiently sensitive in diagnosing EVALI, and radiologists and clinicians should exercise caution when excluding EVALI based on the lack of a pulmonary opacity. Caution should also be exercised when excluding EVALI solely based on the lack of respiratory symptoms. Despite extensive pulmonary involvement at presentation, findings may resolve on short-term follow-up imaging.
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http://dx.doi.org/10.1007/s00247-020-04698-xDOI Listing
August 2020

Value of emergent pediatric cardiac computed tomographic angiography service: initial experience at a large children's hospital.

Pediatr Radiol 2020 07 3;50(8):1095-1101. Epub 2020 Apr 3.

Edward B. Singleton Department of Pediatric Radiology, Texas Children's Hospital, 6701 Fannin St., Suite 470, Houston, TX, 77030, USA.

Background: Demand for pediatric cardiac computed tomography (CT) angiography is increasing due to recent advances that reduce the need for sedation and radiation exposure while enhancing diagnostic accuracy. This has resulted in the increasing use of cardiac CT angiography emergently during weekends and after hours. The unexpected demand for these services can be challenging, as most hospitals are not staffed to provide 24/7 pediatric cardiovascular imaging.

Objective: To describe a large single-center experience of providing emergent cardiac CT angiography services in children.

Materials And Methods: We identified all patients who underwent after--hours weekday and weekend emergent cardiac CT angiography between January 2017 and August 2018. Cardiac CT angiography in the settings of congenital heart disease and coronary imaging were included. Data collected included day and time of cardiac CT angiography, patient age, referral unit, indication, surgical history, need for sedation, need for surgery, intervention and/or change in medical management based on the cardiac CT angiography.

Results: Forty-seven studies were identified, 26 (55%) of which were performed on a weekend or holiday and 21 (45%) after 5 p.m. on a weekday. Based on cardiac CT angiography findings, 20 (43%) patients underwent either surgery or an interventional procedure, and 9 (19%) had a change in medical management. The time between cardiac CT angiography and the related surgery/intervention ranged from 0 to 29 days with a median of 3.5 days.

Conclusion: Emergent pediatric cardiac CT angiography is a valuable service. Larger multi-institutional studies with standardized referral and utilization patterns are needed to determine if outcomes are affected by this service, which in turn will influence hospital staffing patterns for emergent imaging.
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http://dx.doi.org/10.1007/s00247-020-04659-4DOI Listing
July 2020

Correlation of ductus arteriosus length and morphology between computed tomographic angiography and catheter angiography and their relation to ductal stent length.

Pediatr Radiol 2020 05 13;50(6):800-809. Epub 2020 Mar 13.

The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA.

Background: Patent ductus arteriosus (PDA) stent placement in infants with ductal-dependent pulmonary blood flow is being increasingly used in clinical practice.

Objective: To correlate computed tomographic (CT) angiography morphology and length of the PDA with catheter angiography and its relation to eventual PDA stent length.

Materials And Methods: We retrospectively identified all pediatric patients who underwent PDA stenting at our institute from 2004 to 2018. We included children who had CT angiography prior to stenting. PDA length was measured by a radiologist blinded to the catheter angiography data, using Syngo-via post-processing software (Siemens, Erlangen, Germany). Vessel centerline technique was used. We measured the actual length of the duct as well as straight length between aortic and pulmonary ends. PDA morphology tortuosity index was classified as straight (Type I), mildly tortuous with 1 turn (Type II) and tortuous with >1 turn (Type III), and the PDA origin was noted. The PDA was also measured and morphology classified on catheter angiography by an interventional cardiologist blinded to the CT angiography findings. We compared the CT angiography and catheter angiography lengths, straight lengths and stent length using scatter plots and intraclass correlation coefficient (ICC).

Results: A total of 83 children who had PDA stenting were identified, of whom 17 had prior CT angiography. Fifteen of these were neonates. There was agreement between CT angiography and catheter angiography regarding the PDA morphology tortuosity index in 94% of cases and PDA origin in 100% of cases. There was moderate agreement between CT angiography and catheter angiography actual and straight PDA lengths, with ICC coefficients of 0.65 and 0.68, respectively. There was moderate agreement between CT angiography actual length, CT angiography straight length, catheter angiography actual length and eventual stented PDA length, with ICCs of 0.57, 0.67 and 0.73, respectively. There was poor agreement between catheter angiography straight length and eventual stented PDA length, with an ICC of 0.39.

Conclusion: PDA length and morphology description on CT angiography correlates well with catheter angiography and can be a reliable guide for the interventional cardiologist in decision-making regarding appropriate choice of PDA stent length.
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http://dx.doi.org/10.1007/s00247-020-04624-1DOI Listing
May 2020

Outcomes in Anomalous Aortic Origin of a Coronary Artery Following a Prospective Standardized Approach.

Circ Cardiovasc Interv 2020 02 13;13(2):e008445. Epub 2020 Feb 13.

Texas Center for Pediatric and Congenital Heart Disease, University of Texas Dell Medical School/Dell Children's Medical Center, Austin (C.M.M., C.D.F.).

Background: Anomalous aortic origin of a coronary artery (CA) is the second leading cause of sudden cardiac death in young athletes. Management is controversial and longitudinal follow-up data are sparse. We aim to evaluate outcomes in a prospective study of anomalous aortic origin of CA patients following a standardized algorithm.

Methods: Patients with anomalous aortic origin of a CA were followed prospectively from December 2012 to April 2017. All patients were evaluated following a standardized algorithm, and data were reviewed by a dedicated multidisciplinary team. Assessment of myocardial perfusion was performed using stress imaging. High-risk patients (high-risk anatomy-anomalous left CA from the opposite sinus, presence of intramurality, abnormal ostium-and symptoms or evidence of myocardial ischemia) were offered surgery or exercise restriction (if deemed high risk for surgical intervention). Univariate and multivariable analyses were used to determine predictors of high risk.

Results: Of 201 patients evaluated, 163 met inclusion criteria: 116 anomalous right CA (71%), 25 anomalous left CA (15%), 17 single CA (10%), and 5 anomalous circumflex CA (3%). Patients presented as an incidental finding (n=80, 49%), with exertional (n=31, 21%) and nonexertional (n=32, 20%) symptoms and following sudden cardiac arrest/shock (n=5, 3%). Eighty-two patients (50.3%) were considered high risk. Predictors of high risk were older age at diagnosis, black race, intramural course, and exertional syncope. Most patients (82%) are allowed unrestrictive sports activities. Forty-seven patients had surgery (11 anomalous left CA and 36 anomalous right CA), 3 (6.4%) remained restricted from sports activities. All patients are alive at a median follow-up of 1.6 (interquartile range, 0.7-2.8) years.

Conclusions: In this prospective cohort of patients with anomalous aortic origin of a CA, most have remained free of exercise restrictions. Development of a multidisciplinary team has allowed a consistent approach and may have implications in risk stratification and long-term prognosis.
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http://dx.doi.org/10.1161/CIRCINTERVENTIONS.119.008445DOI Listing
February 2020

Delayed diagnosis of posterior ankle impingement in pediatric and adolescent patients: does radiology play a role?

Pediatr Radiol 2020 02 9;50(2):216-223. Epub 2019 Nov 9.

E. B. Singleton Department of Pediatric Radiology, Texas Children's Hospital, 6701 Fannin St., Suite 470, Houston, TX, 77030, USA.

Background: Posterior ankle impingement syndrome (PAIS) results from the pinching of anatomical structures in the posterior part of the ankle.

Objective: To identify the possible role of imaging in the delayed diagnosis of PAIS and identify key findings on imaging to suggest PAIS in pediatric and adolescent patients.

Materials And Methods: Data were collected prospectively in patients younger than 18 years of age who underwent arthroscopy after being diagnosed with PAIS. Imaging was reviewed retrospectively by two radiologists, compared with findings in literature and an age-matched control group, and correlated with arthroscopic findings. Pre- and postsurgical Visual Analogue Scale (VAS) pain and American Orthopedic Foot Ankle Society (AOFAS) ankle-hindfoot scores were noted.

Results: Thirty-eight patients (20 females, 18 males), 51 ankles, with an average age of 12.9 years had an average 18-month delay in diagnosis. Twenty-seven of the 38 (73%) patients had previously seen multiple medical providers and were given multiple misdiagnoses. Radiographs were reported normal in 34/47 (72%) ankles. Thirty patients had magnetic resonance imaging (MRI) and findings included the presence of an os trigonum/Stieda process (94%) with associated osseous edema (69%), flexor hallucis longus (FHL) tenosynovitis (16%), and edema in Kager's fat pad (63%). Although individual findings were noted, the impression in the MRI reports in 16/32 (50%) did not mention PAIS as the likely diagnosis. There was a significant difference in the MRI findings of ankle impingement in the patient population when compared to the control group. Surgery was indicated after conservative treatment failed. All 51 ankles had a PAIS diagnosis confirmed during arthroscopy. At an average follow-up of 10.2 months, there was improvement of VAS pain (7.0 to 1.1) and AOFAS ankle-hindfoot scores (65.1 to 93.5).

Conclusion: PAIS as a diagnosis is commonly delayed clinically in young patients with radiologic misinterpretation being a contributing factor. Increased awareness about this condition is needed among radiologists and physicians treating young athletes.
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http://dx.doi.org/10.1007/s00247-019-04547-6DOI Listing
February 2020

A novel approach using volumetric dynamic airway computed tomography to determine positive end-expiratory pressure (PEEP) settings to maintain airway patency in ventilated infants with bronchopulmonary dysplasia.

Pediatr Radiol 2019 09 16;49(10):1276-1284. Epub 2019 Jul 16.

Nationwide Children's Hospital, Columbus, OH, USA.

Background: Positive end-expiratory pressure (PEEP) is a key mechanical ventilator setting in infants with bronchopulmonary dysplasia (BPD). Excessive PEEP can result in insufficient carbon dioxide elimination and lung damage, while insufficient PEEP can result in impaired gas exchange secondary to airway and alveolar collapse. Determining PEEP settings based on clinical parameters alone is challenging and variable.

Objective: The purpose of this study was to describe our experience using dynamic airway CT to determine the lowest PEEP setting sufficient to maintain expiratory central airway patency of at least 50% of the inspiratory cross-sectional area in children with BPD requiring long-term ventilator support.

Materials And Methods: We retrospectively identified all infants with BPD who underwent volumetric CT with a dynamic airway protocol for PEEP optimization from December 2014 through April 2019. Sixteen infants with BPD underwent 17 CT exams. Each CT exam consisted of acquisitions spanning the trachea and mainstem bronchi. We measured cross-sectional area of the trachea and mainstem bronchi and qualitatively assessed the amount of atelectasis. We documented changes in management as a result of the CT exam.

Results: The average effective dose was 0.1-0.8 mSv/scan. Of 17 CT exams, PEEP was increased in 9, decreased in 3 and unchanged after 5 exams.

Conclusion: Dynamic airway CT shows promise to assist the clinician in determining PEEP settings to maintain airway patency in infants with BPD requiring long-term ventilator support. Further evaluation of the impact of this maneuver on gas exchange, cardiac output and other physiological measures is needed.
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http://dx.doi.org/10.1007/s00247-019-04465-7DOI Listing
September 2019

Spontaneous healing of avascular necrosis of the femoral head in sickle cell disease.

Am J Hematol 2019 06 18;94(6):E160-E162. Epub 2019 Mar 18.

Division of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas.

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http://dx.doi.org/10.1002/ajh.25453DOI Listing
June 2019

Modified Friedman technique: a new proposed method of measuring glenoid version in the setting of glenohumeral dysplasia.

Pediatr Radiol 2018 11 5;48(12):1779-1785. Epub 2018 Jul 5.

Pediatric Radiology, Texas Children's Hospital, 6701 Fannin St., Houston, TX, 77030, USA.

Background: Glenoid version angles are measured to objectively follow changes related to glenohumeral dysplasia in the setting of brachial plexus birth palsy. Measuring glenoid version on cross-sectional imaging was initially described by Friedman et al. in 1992. Recent literature for non-dysplastic shoulders advocates time-consuming reconstructions and reformations for an accurate assessment of glenoid version.

Objective: To compare Friedman's original method for measuring glenoid version to a novel technique we developed ("modified Friedman") with the reference standard of true axial reformations.

Materials And Methods: With institutional review board approval, we retrospectively examined 30 normal and dysplastic shoulders obtained from magnetic resonance imaging examinations of 30 patients with an established diagnosis of brachial plexus birth palsy between January 2012 and September 2017. Four pediatric radiologists performed glenoid version measurements using Friedman's method, the modified Friedman method and a previously described true axial reformation method. The modified Friedman technique better accounts for scapular positioning by selecting a reference point related to the acromion-scapular body interface. Inter-rater reliability and inter-method agreement were assessed using intraclass correlation, paired t-tests and mixed linear model analysis. Equivalence tests between methods were performed per reader.

Results: Glenoid version measurements were significantly different when comparing Friedman's method to true axial reformations in normal (-10.8±5.7° [mean±standard deviation] vs. -8.8±5.3°; P≤0.001) and dysplastic shoulders (-34.6±17.7° vs. -28.1±17.5°; P≤0.001). Glenoid version measurements were not significantly different when comparing the modified Friedman's method to true axial reformations in normal (-6.3±5.8° vs. -8.8±5.3°; P=0.06) and dysplastic shoulders (-29.0±18.3° vs. -28.1±17.5°; P=0.06). Friedman's method was not equivalent to true axial reformations for measurements in dysplastic shoulders for all readers (P=0.68, 0.81, 0.86, 0.99); the modified Friedman method was equivalent to of true axial reformations for measurements in dysplastic shoulders for 3 of 4 readers (P≤0.001, P≤0.001, P≤0.001, P=0.10).

Conclusion: In glenohumeral dysplasia, the modified Friedman method and post-processed true axial reformations provide statistically similar and reproducible values. We propose that our modified Friedman technique can be performed in lieu of post-processed true axial reformations to generate glenoid version measurements.
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http://dx.doi.org/10.1007/s00247-018-4196-7DOI Listing
November 2018

Utility of immediate postoperative hip MRI in developmental hip dysplasia: closed vs. open reduction.

Pediatr Radiol 2018 08 25;48(8):1096-1100. Epub 2018 Apr 25.

E.B. Singleton Department of Pediatric Radiology, Texas Children's Hospital, 6701 Fannin St., Suite 470, Houston, TX, 77030-2399, USA.

Background: Magnetic resonance imaging (MRI) of the hips is being increasingly used to confirm hip reduction after surgery and spica cast placement for developmental dysplasia of the hip (DDH).

Objective: To review a single institutional experience with post-spica MRI in children undergoing closed or open hip reduction and describe the utility of MRI in directing the need for re-intervention.

Materials And Methods: Seventy-four patients (52 female, 22 male) who underwent post-spica hip MRI over a 6-year period were retrospectively reviewed. One hundred and seven hips were included. Data reviewed included age at intervention, gender, type of intervention performed, MRI findings, the need for re-intervention and the interval between interventions. Gender was compared between the closed and open reduction groups via the Fisher exact test. Age at the first procedure was compared via the Wilcoxon rank test. Rates of re-intervention after closed and open reduction were calculated and the reasons for re-intervention were reviewed.

Results: The mean age at the time of the first intervention was 16.4 months (range: 4 to 63 months). Mean age for the closed reduction group was 10.5 months (range: 4-24 months) and for the open reduction group was 23.7 months (range: 5-63 months), which was significant (P-value <0.0001). Of the 52 hips that underwent closed reduction, 16 (31%) needed re-intervention. Of the 55 hips that underwent open reduction, MRI was useful in deciding re-intervention in only 1 (2%). This patient had prior multiple failed closed and open reductions at an outside institute.

Conclusion: Post intervention hip spica MRI is useful in determining the need for re-intervention after closed hip reduction, but its role after open reduction is questionable.
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http://dx.doi.org/10.1007/s00247-018-4143-7DOI Listing
August 2018

Radiopathologic correlation of a tricuspid valve papillary fibroelastoma detected in an infant.

Radiol Case Rep 2017 Dec 13;12(4):668-671. Epub 2017 Sep 13.

Department of Radiology, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin Street Suite 470, Houston, TX 77030.

Papillary fibroelastomas are benign primary cardiac tumors that usually arise from the valve apparatus and are rare in the pediatric population. Involvement of the tricuspid valve is even less common with only a few cases reported in the literature. Cardiac magnetic resonance imaging is a valuable examination that aids in differentiating a tumor from a thrombus. We present the case of an 11-month-old girl referred by her pediatrician to investigate a murmur noted since birth. To our knowledge, this is the first report of a pathologically proven papillary fibroelastoma arising from the tricuspid valve characterized by magnetic resonance imaging in an infant.
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http://dx.doi.org/10.1016/j.radcr.2017.08.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5823306PMC
December 2017

Searching for certainty: findings predictive of appendicitis in equivocal ultrasound exams.

Pediatr Radiol 2016 Oct 9;46(11):1539-45. Epub 2016 Jun 9.

Edward B. Singleton Department of Pediatric Radiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA.

Background: Ultrasound (US) is the preferred imaging modality for evaluating suspected pediatric appendicitis. However, borderline appendiceal enlargement or questionable inflammatory changes can confound interpretation and lead to equivocal exams.

Objective: The purpose of this study was to determine which findings on equivocal US exams are most predictive of appendicitis.

Materials And Methods: All US exams performed for suspected pediatric appendicitis from July 1, 2013, through July 9, 2014, were initially interpreted using a risk-stratified scoring system. Two blinded pediatric radiologists independently reviewed US exams designated as equivocal and recorded the following findings: increased wall thickness, loss of mural stratification, peri-appendiceal fat inflammation, peri-appendiceal fluid, appendicolith and maximum appendiceal diameter. A third pediatric radiologist resolved discrepancies. US features were correlated with the final diagnosis via multivariate analysis.

Results: During the study period, 162/3,750 (4.3%) children had US exams initially interpreted as equivocal (mean age 9.8 +/- 3.8 years). Five outpatients were lost to follow-up. Forty-eight of the remaining 157 (30.6%) children had an operative diagnosis of appendicitis. Findings significantly associated with appendicitis were loss of mural stratification (odds ratio [OR] = 6.7, P=0.035), peri-appendiceal fat inflammation (OR = 10.0, P<0.0001) and appendicolith (OR = 15.8, P=0.025). While appendiceal diameter tended to be larger in patients with appendicitis, the difference was not statistically significant.

Conclusion: Loss of mural stratification, peri-appendiceal fat inflammation and an appendicolith are significant predictors of appendicitis in children with otherwise equivocal US exams. While maximum appendiceal diameter is not statistically associated with appendicitis in our study, mean appendiceal diameter of 6.7 mm in those without appendicitis suggests that the customary upper normal limit of 6 mm is too sensitive.
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http://dx.doi.org/10.1007/s00247-016-3645-4DOI Listing
October 2016

Erratum to: Non-fecalith-induced appendicitis: etiology, imaging, and pathology.

Emerg Radiol 2016 Jun;23(3):313-314

Department of Surgery-General Surgery, The University of Texas Medical Branch, Galveston, TX, USA.

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http://dx.doi.org/10.1007/s10140-016-1388-zDOI Listing
June 2016

Non-fecalith-induced appendicitis: etiology, imaging, and pathology.

Emerg Radiol 2015 Dec 21;22(6):643-9. Epub 2015 Aug 21.

Department of Surgery-General Surgery, The University of Texas Medical Branch, Galveston, TX, USA.

This study aims to document the imaging and pathology findings in non-fecalith-induced appendicitis. We reviewed the imaging and pathologic findings in 40 patients with histologically proven purulent appendicitis seen over a 2-year period. Findings documented were (1) total appendiceal involvement, (2) predominant appendiceal tip involvement, (3) presence of a fecalith, and (4) presence of lymphoid hyperplasia. There were a total of 40 patients, 28 males and 12 females. The age range was 2-18 years with a mean of 11.5 years. Twenty-two (55 %) patients demonstrated classic purulent appendicitis of the whole appendix, 20 (91 %) of these appendices had a fecalith. Eighteen (45 %) patients demonstrated purulent appendicitis confined to or predominately involving the tip of the appendix, and all 18 (100 %) patients demonstrated marked lymphoid hyperplasia. Only two (11 %) of these appendices had a fecalith. Overall, a fecalith was found in only 55 % of our cases, while 45 % demonstrated no fecalith, but rather marked lymphoid hyperplasia. Lymphoid hyperplasia appeared to be the underlying predisposing cause of purulent appendicitis in these cases.
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http://dx.doi.org/10.1007/s10140-015-1338-1DOI Listing
December 2015

CT angiography of neonates and infants: comparison of radiation dose and image quality of target mode prospectively ECG-gated 320-MDCT and ungated helical 64-MDCT.

AJR Am J Roentgenol 2015 Feb;204(2):W184-91

1 EB Singleton Department of Pediatric Radiology, Texas Children's Hospital, 6621 Fannin St, Houston, TX 77030.

OBJECTIVE. The purpose of this study was to evaluate the radiation dose and image quality of target mode prospectively ECG-gated volumetric CT angiography (CTA) performed with a 320-MDCT scanner compared with the radiation dose and image quality of ungated helical CTA performed with a 64-MDCT scanner. MATERIALS AND METHODS. An experience with CTA for cardiovascular indications in neonates and infants 0-6 months old was retrospectively assessed. Radiation doses and quantitative and qualitative image quality scores of 28 CTA examinations performed with a 320-MDCT scanner and volumetric target mode prospective ECG gating plus iterative reconstruction (target mode) were compared with the doses and scores of 28 CTA examinations performed with a 64-MDCT scanner and ungated helical scanning plus filtered back projection reconstruction (ungated mode). All target mode studies were performed during free breathing. Seven ungated CTA examinations (25%) were performed with general endotracheal anesthesia. The findings of 17 preoperative CTA examinations performed in target mode were also compared with surgical reports for evaluation of diagnostic accuracy. RESULTS. All studies performed with target mode technique were diagnostic for the main clinical indication. Effective doses were significantly lower in the target mode group (0.51 ± 0.19 mSv) compared with the ungated mode group (4.8 ± 1.4 mSv) (p < 0.0001). Quantitative analysis revealed no statistically significant difference between the two groups with respect to signal-to-noise ratio (of pulmonary artery and aorta) and contrast-to-noise ratio. Subjective image quality was significantly better with target mode than with ungated mode (p < 0.0001). CONCLUSION. Target mode prospectively ECG-gated volumetric scanning with iterative reconstruction performed with a 320-MDCT scanner has several benefits in cardiovascular imaging of neonates and infants, including low radiation dose, improved image quality, high diagnostic accuracy, and ability to perform free-breathing studies.
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http://dx.doi.org/10.2214/AJR.14.12846DOI Listing
February 2015

Inferior patellar pole fragmentation in children: just a normal variant?

Pediatr Radiol 2015 Jun 7;45(6):882-7. Epub 2014 Dec 7.

E.B. Singleton Pediatric Radiology, Texas Children's Hospital, 6701 Fannin Street, Suite 470, Houston, TX, 77030-2399, USA.

Background: Fragmentary ossification of the inferior patella is often dismissed as a normal variant in children younger than 10 years of age.

Objective: The purpose of this study was to determine whether fragmentary inferior patellar pole ossification is a normal variant or is associated with symptoms or signs of pathology using MRI and clinical exam findings as reference.

Materials And Methods: A retrospective review was performed on 150 patients ages 5-10 years who underwent 164 knee radiography and MRI exams (45.1% male, mean age: 7.8 years). The presence or absence of inferior patellar pole fragmentation on radiography was correlated with the presence or absence of edema-like signal on MR images. Clinical notes were reviewed for the presence of symptoms or signs referable to the inferior patellar pole. These data were compared with a 1:1 age- and sex-matched control group without inferior pole fragmentation. Statistical analysis was performed using two-tailed t-tests.

Results: Forty of 164 (24.4%) knee radiographs showed fragmentary ossification of the inferior patella. Of these 40 knees, 62.5% (25/40) had edema-like signal of the inferior patellar bone marrow compared with 7.5% (3/40) of controls (P = 0.035). Patients with fragmentary ossification at the inferior patella had a significantly higher incidence of documented focal inferior patellar pain compared with controls (20% vs. 2.5%, P = 0.015).

Conclusion: Inferior patellar pole fragmentation in children 5 to 10 years of age may be associated with localized symptoms and bone marrow edema-like signal and should not be routinely dismissed as a normal variant of ossification.
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http://dx.doi.org/10.1007/s00247-014-3240-5DOI Listing
June 2015

Comprehensive review of the anatomy, function, and imaging of the popliteus and associated pathologic conditions.

Radiographics 2014 Mar-Apr;34(2):496-513

From the Edward B. Singleton Department of Pediatric Radiology, Texas Children's Hospital, 6701 Fannin St, Suite 470, Houston, TX 77030 (S.P.J.); Department of Radiology, University of Texas Medical Branch, Galveston, Tex (S.R.M., R.F.R., L.E.S.); and University of Vermont Medical Group, Burlington, Vt (D.F.L.).

The popliteus is a relatively small but unique muscle of the knee. It is a component of the posterolateral corner of the knee and acts as a major stabilizer of the posterolateral knee. It is important to be aware of the normal magnetic resonance (MR) imaging appearance of the popliteus musculotendinous complex and its relation to other structures of the posterolateral corner for accurate diagnosis. It is also important to be aware of the pitfalls in imaging of the popliteus. Dysfunction of the popliteus is often underappreciated and is usually secondary to direct or indirect trauma. Injuries of the popliteus can be classified as first-, second-, or third-degree strains. Injuries of the popliteus are often associated with other posterolateral corner injuries. Pathologic conditions of the popliteus may be a clue to other injuries in the knee. The site and pattern of popliteus tear can be helpful to the orthopedic surgeon in deciding whether repair is warranted and determining the approach to surgery and has prognostic implications. Undiagnosed popliteus injuries can lead to poor functional results after knee reconstructive surgery. Inflammatory pathologic conditions of the popliteus may cause knee pain and can be diagnosed with MR imaging. The popliteus is an important component of the posterolateral corner that needs closer attention for optimal diagnosis and patient care.
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http://dx.doi.org/10.1148/rg.342125082DOI Listing
January 2015

Tibial stress phenomena and fractures: imaging evaluation.

Emerg Radiol 2014 Apr 30;21(2):173-7. Epub 2013 Nov 30.

The University of Texas Medical Branch, Galveston, TX, USA,

This study aims to evaluate the various imaging modalities used to diagnose tibial stress-fractures/phenomena and determine which of these are most useful and definitive. The plain film, computed tomography (CT), magnetic resonance (MR), and nuclear medicine findings in a 20-patient cohort, ranging from ages 10 to 21 years with an average of 16 years, were reviewed. The male to female ratio was recorded as was the incidence of right or left, or bilateral extremity involvement. Thereafter, each imaging modality was evaluated for positive findings. Twelve of the patients had pretibial swelling on plain films, 10 a thickened cortex, to a visible fracture on plain films and 13 had increased short-tau inversion recovery (STIR) signal in the post tibial (marrow) and pretibial (subperiosteum) areas on MR imaging. No CT studies were performed. One positive nuclear medicine study was available. Although there are a number of imaging modalities which can be used to evaluate the tibial stress/fracture phenomena problem, it would appear that plain films and MR studies are most useful. If plain films do not show a fracture and further information is required, an MR study is most appropriate.
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http://dx.doi.org/10.1007/s10140-013-1181-1DOI Listing
April 2014

Radiographic findings in late-presenting congenital diaphragmatic hernia: helpful imaging findings.

Pediatr Radiol 2012 Mar 3;42(3):337-42. Epub 2011 Sep 3.

Department of Pediatric Radiology, The University of Texas Medical Branch, 301 University Blvd., Galveston, TX 77555-0585, USA.

Background: Imaging findings in delayed presentation of congenital diaphragmatic hernia can be confusing and misleading, resulting in a delay in diagnosis.

Objective: To evaluate the often puzzling plain film findings of late-presenting CDH in an effort to determine whether any of the findings could be helpful in arriving at an early diagnosis.

Material And Methods: We reviewed and documented the plain film findings and clinical data in eight patients seen during the last 20 years with late-presenting CDH. IRB exempt status was obtained in this study.

Results: There were five boys and three girls. The age range was 4 months to 12 years with a mean of 2.4 years. Five children presented with acute respiratory problems while three presented with acute abdominal pain. Two children presented with both respiratory and abdominal findings and one also presented with hematemesis. Two children had radiographic findings that were not difficult to analyze while the remaining six had findings that posed initial diagnostic problems.

Conclusion: Although not common, late-presenting CDH can result in confusing plain film radiographic findings and a delay in diagnosis. We found that the most important finding in analyzing these radiographs is in evaluating the location and position of the gastric bubble with the more common left-side hernias.
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http://dx.doi.org/10.1007/s00247-011-2226-9DOI Listing
March 2012

Morel-Lavallee seroma: a review of two cases in the lumbar region in the adolescent.

Emerg Radiol 2011 Dec 11;18(6):495-8. Epub 2011 Aug 11.

Department of Radiology, The University of Texas Medical Branch, Galveston, TX 77555-0585, USA.

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http://dx.doi.org/10.1007/s10140-011-0975-2DOI Listing
December 2011

MR imaging of pediatric trauma.

Magn Reson Imaging Clin N Am 2009 Aug;17(3):439-50, v

Division of Pediatric Radiology, Department of Radiology, University of California, Davis Medical Center and UC Davis Children's Hospital, 4860 Y Street, Suite 3100, Sacramento, CA 95817, USA.

Although plain radiography remains the most important and cost-effective imaging for screening and characterizing osseous injuries, it has been well recognized that pediatric fractures can occur without radiographic abnormalities. The superb capability of MR imaging in demonstrating marrow edema, cartilage defects, and soft tissue injuries makes it an essential adjunct in the further evaluation of trauma to the growing skeleton. The key MR imaging findings of growth plate injuries, stress fractures, avulsion injuries, osteochondritis dissecans, transient patellar dislocation, and soft tissue injuries are described in this article.
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http://dx.doi.org/10.1016/j.mric.2009.03.007DOI Listing
August 2009

Calcific discitis in children: vertebral body involvement (possible insight into etiology).

Emerg Radiol 2008 Nov 8;15(6):427-30. Epub 2008 Jul 8.

UTMB, Galveston, TX, USA.

The aim of the study was to present our cases of calcific discitis, analyze the imaging findings, and review the literature in an attempt to formulate a possible etiology. We reviewed the imaging and clinical findings in nine patients with calcific discitis and accomplished a literature review of the condition. There were nine patients, five males and four females. Age range was 5-13 years with a mean of 9.7 years. Twenty-three discs were involved, nine cervical and fourteen thoracic. Four cervical discs were not calcified but merely swollen. One patient presented with abnormal magnetic resonance (MR) signal changes within a vertebral body. Our literature search revealed another such patient and brought up the possibility that the insult to the disc might be secondary to vertebral body involvement and disruption of the tenuous vascular/nutritional support of the intervertebral disc from the adjacent vertebral body. In the early stages of calcific discitis, only swelling and expansion of the disc are seen. More recently, with MR imaging, vertebral body involvement has been demonstrated to also occur. As a result, it may be that the initial insult (vascular compromise) is to the vertebral body (nutritional support for the disc) rather than to the disc.
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http://dx.doi.org/10.1007/s10140-008-0739-9DOI Listing
November 2008

Commonly missed subtle skeletal injuries in children: a pictorial review.

Emerg Radiol 2008 Nov 28;15(6):391-8. Epub 2008 May 28.

Department of Radiology, The University of Texas Medical Branch, Galveston, TX 77555, USA.

Children are distinctive as compared to adults when it comes to musculoskeletal injuries. This is due to the relative elasticity of bones and the presence of epiphyseal plates. There are many subtle injuries which will be missed if the radiologist is not aware of them and is not actively searching for them. The common elusive injuries include: (1) plastic bending fractures, (2) sternoclavicular dislocation, (3) epiphyseal-metaphyseal injuries in older child, (4) buckle fractures, and (5) Toddler fracture types I and II. Detection of these injuries needs an accurate history, a good physical examination, and, in particular, a thorough search by the radiologist. In many cases, it is the radiologist who suggests likelihood of the injury and guides management. In this respect, the use of comparative views and, in some cases, additional imaging is warranted. Here, we review the elusive musculoskeletal injuries in children in pictorial form.
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http://dx.doi.org/10.1007/s10140-008-0733-2DOI Listing
November 2008

Aortic injury with Chance fracture in a child.

Emerg Radiol 2008 Sep 22;15(5):285-7. Epub 2008 Apr 22.

Pediatric Radiology Section, Department of Radiology, the University of Texas Medical Branch, Galveston, TX 77555-0365, USA.

To present the findings in a 10-year-old male with a Chance fracture and associated aortic vascular injury and review of the literature on the subject. We reviewed the clinical and imaging findings in a patient who was in a serious motor vehicle accident, sustaining a Chance fracture of the lumbar spine and associated aortic and common iliac vessel injury. We also accomplished a literature review. Evidence of an associated aortic injury was available on the initial computed tomography (CT) study, but the findings were more exquisitely demonstrated on reconstructed studies of the lumbar spine. Our literature review indicated that aortic injury associated with Chance fracture is relatively rare and often overlooked. Abdominal aortic injury although rare, can occur with Chance fractures. With the now present sophisticated CT imaging in most Emergency Rooms it is possible to obtain exquisite reconstructed images of all organ systems including the vascular tree. The images may provide enough details so that further delineation of any given problem may not be necessary.
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http://dx.doi.org/10.1007/s10140-008-0722-5DOI Listing
September 2008