What is the most common malignant renal tumor in the pediatric population? a. Wilm’s tumor
c. Renal cell carcinoma
d. Mesoblastic nephroma
15. A 3-year-old presents with a palpable right sided fl ank mass. Sonographically, a large, homogeneous, well-circumscribed mass is seen extending from the superior pole of the right kidney. A few cystic spaces are noted within the lesion. What is the most likely diagnosis? a. Mesoblastic nephroma
b. Renal cell carcinoma
c. Wilm’s tumor
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188 PART 3 — NEONATAL AND PEDIATRIC SONOGRAPHY
16. A neonate is born with a palpable left fl ank mass. Sonography reveals a large solid homogeneous mass in the left kidney. Very little normal renal parenchyma is seen. What is the most likely diagnosis in this age group? a. Mesoblastic nephroma
b. Renal cell carcinoma
c. Wilm’s tumor
17. A 2-month-old infant presents with an enlarging, palpable left fl ank mass and mild hypertension. Sonographically, a large, solid, ill-defi ned echogenic mass is seen superior to the left kidney. Calcifi cations with shadowing are present within the mass. The kidney appears to be displaced inferiorly. What is the most likely diagnosis? a. Wilm’s tumor
b. Adrenal hemorrhage
d. Adrenal metastasis
18. What is the most common children adrenal tumor? a. Wilm’s tumor
19. Which of the following statements regarding adrenal hemorrhage is FALSE? a. Adrenal hemorrhage is typically diagnosed when
the infant is 1 month old
b. Infants who are premature or have neonatal sepsis, hypoxia, and birth trauma may develop an adrenal hemorrhage
c. Jaundice may occur, as well as scrotal discoloration in male infants
d. Blunt abdominal trauma or child abuse may cause hemorrhage in older infants
20. Which statement regarding the location of the adrenal glands is TRUE? a. The adrenal glands are located within the anterior
b. The right adrenal gland lies between the right crus of the diaphragm and the liver, posterior to the IVC
c. The left adrenal gland is medial and to the right of the left crus of the diaphragm and anterior to the pancreatic tail
d. With renal agenesis, the adrenal glands are typically harder to locate
1. Renal are seen as an irregular renal
outline and are commonly seen in
but should disappear by about
2. The cortical echogenicity of the kidneys in neonates
and infants, particularly infants,
is than that in older children.
3. The normal renal artery in a pediatric patient should
demonstrate a sharp peak with
continuous forward fl ow.
4. The resistive indices can help determine if a
dilated urinary system is . The
RI is increased in disease and
5. Bilateral renal agenesis is associated with
, or a decrease in amniotic fl uid,
6. A dilation of the collecting system, specifi cally the
renal calyces, the renal pelvis, and ureters is called
. The three most common causes
obstruction, and .
7. With hydronephrosis there should be recognizable
renal surrounding the
dilated collecting system. In cases of bilateral
hydronephrosis, the obstruction is going to be
located in the or
8. In patients with prune belly syndrome, the bladder is
and , whereas in
a patient with posterior urethral valves the bladder is
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20 — The Pediatric Urinary System and Adrenal Glands 189
develops from complete
ureteral obstruction in utero. If the condition is
, it is inconsistent with life.
10. Renal hypoplasia is a but
otherwise normal kidney and most often results
from atrophy secondary to or from
11. Tuberous sclerosis can present with bilateral renal
12. Wilm’s tumor typically presents as a
but may also
present with , ,
, and .
13. The peak age for a Wilm’s tumor is
years. Wilm’s tumor may be
and may invade the vein and
14. A cystic renal mass that appears as multiple
thin-walled cysts or a large cyst with septations
15. The most common sonographic fi nding in cases
of pyelonephritis is of the
kidneys. Areas of or, less often,
echogenicity may also be seen.
16. A solid bladder tumor that can occur in the pediatric
population and may cause hematuria, dysuria,
retention, and UTI is called .
17. A neuroblastoma typically occurs in
and rarely after the age of .
They tend to have -defi ned borders
and are common.
18. A rare functioning adrenal tumor that
originates in the chromaffi n tissue is called
. Common clinical symptoms
include , ,
, and .
19. The adrenal glands are susceptible to hemorrhage
due to their and
high . Adrenal hemorrhage is most
commonly identifi ed between the
20. Adrenal abscess are the result of neonatal
and are usually .
Clinical symptoms include ,
1. Describe the differences in the sonographic appearance of the kidneys in infants, children, and adults.
2. Describe how hydronephrosis and multicystic dysplastic kidney can be distinguished sonographically.
3. When evaluating an abdominal mass, the sonographer must determine three important factors to make an accurate diagnosis. Describe the three factors.
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190 PART 3 — NEONATAL AND PEDIATRIC SONOGRAPHY
4. Describe how a Wilm’s tumor would be differentiated from a neuroblastoma sonographically.
5. Describe how a neuroblastoma would be differentiated from an adrenal hemorrhage sonographically.
Review the images and answer the following questions.
1. What pathology is seen in this image of the right kidney? What are the most common causes of this pathology in infants and children?
2. What pathology is seen in this image of the right kidney in a neonate? What liver condition is associated with this renal pathology?
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20 — The Pediatric Urinary System and Adrenal Glands 191
3. A 2-week-old infant presents for a renal sonogram to follow up an abnormality seen on a prenatal sonogram. This image was taken in the right upper quadrant. The left kidney and bladder appear normal. What is the likely diagnosis?
4. A male neonate presents with posterior urethral valves. Bilateral hydronephrosis is seen, with the left kidney worse than the right. A fl uid collection is seen surrounding the right kidney, indicated by the arrows in this image. What does the fl uid most likely represent?
5. An infant presents for a renal sonogram. A duplicated collecting system is seen in the right kidney. The left kidney appears normal. The upper pole collecting system on the right is dilated. This image was taken in the urinary bladder. What are the arrows pointing to?
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192 PART 3 — NEONATAL AND PEDIATRIC SONOGRAPHY
Review the images and answer the following questions.
1. A 3-year-old boy presents with an enlarging palpable mass in the right upper quadrant. A large, solid mass is seen on the right kidney. Very little normal renal tissue is seen in the upper pole. Describe the mass. What is the most likely diagnosis? List the congenital malformations associated with this tumor.
2. A 2-day-old premature newborn has clinical symptoms of anemia and jaundice. An abdominal sonogram is ordered. The only abnormal fi nding is a complex mass superior to the right kidney. What is the most likely diagnosis, given the patient’s age and symptoms? How would you expect this mass to change if a follow-up sonogram is performed in a few weeks?
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REVIEW OF GLOSSARY TERMS
Match the terms with their defi nitions.
Key Terms Defi nitions
3. Choroid plexus
4. Corpus callosum
5. Falx cerebri
a. Lack of oxygen b. Echogenic cluster of cells located within the lateral
ventricles responsible for the production of cerebral spinal fl uid
c. Fold of dura matter that divides the two hemispheres of the brain
d. Largest section of the brain; divided into two hemispheres joined by the corpus callosum
e. Paired ovoid structures in the central brain responsible for relaying nerve impulses and carrying sensory information into the cerebral cortex
f. Posterior portion of the brain composed of two hemispheres
g. Cyst or cavity in the brain, usually the result of a destructive lesion
h. Soft spot between the cranial bones i. Largest white matter structure in the brain; contains
nerve tracts that allow communication between the right and left hemispheres of the brain
21 The Neonatal Brain
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194 PART 3 — NEONATAL AND PEDIATRIC SONOGRAPHY
ANATOMY AND PHYSIOLOGY REVIEW
Complete the labels in the images that follow.
1. Coronal brain
2. Coronal brain
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21 — The Neonatal Brain 195
3. Coronal brain
4. Sagittal midline brain
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196 PART 3 — NEONATAL AND PEDIATRIC SONOGRAPHY
Complete each question by circling the best answer.
1. Which of the following is the primary acoustic window used to image the neonatal brain? a. Mastoid fontanelle
b. Anterior fontanelle
c. Posterior fontanelle
d. Superfi cial fontanelle
2. Excessive pressure on the anterior fontanelle during the examination may cause what? a. Tachycardia
b. Respiratory arrest
d. Image artifacts
3. Which of the following is NOT one of the meninges that cover and protect the brain and spinal cord? a. Pia mater
b. Dura mater
d. Vergae mater
4. Which of the following is NOT one of the four cortical lobes of the brain? a. Frontal
5. Which of the following is NOT contained in the posterior fossa? a. Third ventricle
b. Fourth ventricle
6. Which of the following statements regarding the neonatal brain is FALSE? a. Coronal scanning allows for a comparison of the
echogenicity between the choroid plexus and the periventricular parenchyma
b. The echogenicity of the periventricular white matter should be slightly brighter than the choroid plexus
c. Changes in echogenicity in this area should arouse suspicion for hemorrhage or infarct
d. Evaluating this area through the posterior fontanelle may also be helpful
7. Which of the following statements regarding the premature brain is FALSE? a. In very premature infants, the cavum vergae is
b. In premature infants, the cisterna magna should still be seen
c. Widely spaced sylvian fi ssures on the coronal view is a marker of extreme prematurity
d. The sulci are easily visible, even in a very premature infant
5. Parasagittal brain
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21 — The Neonatal Brain 197
8. A sonogram of the neonatal brain in a preterm infant demonstrates a thickened and irregular left choroid plexus. Echogenic material is also noted in the left occipital horn of the lateral ventricle. What grade of GM-IVH would be assigned to this patient? a. Grade I
b. Grade II
c. Grade III
d. Grade IV