common neonatal Radiology findings

1. To
Seminar
Presented by :
Dr. Sharmin Akhter (year-2)
Resident, PHO
Dr. Md Saiful Islam (year-4)
Resident, Neonatology ,BSMMU
1

2. S/O Lipi Akhter, inborn, 30 minute old boy admitted in NICU
with the complaints of prematurity (31weeks), low birth
weight (1200gm) and respiratory distress soon after birth.
Mother having no h/o taking antenatal corticosteroid
On examination - Baby was cyanosed with 2L/min O₂, good
reflex activities, well perfused, euthermic, euglycaemic, R/R:
70 breaths/min, chest indrawing present, grunting audible
without stethoscope , bilateral poor air entry
Case scenario
2

3. 1. What is you provisional diagnosis?
 Respiratory Distress Syndrome
2. Single investigation you want do first ?
3

4. Radiology in Newborn
4

5. Overview of presentation
 Introduction
 Radiographic examination
Chest radiograph
 Chest x-ray of Common disease in Newborn
 Position of Tubes and Catheters
Abdominal radiograph
 Common disease in on plain abdominal X-ray
Contrast studies
 Common disease in Newborn on Contrast X-ray
5

6. Introduction
Radiography is a great and useful tool for diagnosis of
Neonatal diseases
The x-ray is one of the most frequently requested
radiological examinations in neonatal intensive care
units
The corner stone of imaging is still conventional
radiography but ultrasound plays an important part
6

7. Radiographic examination
 Chest radiograph
 Abdominal radiograph
 Babygram
 Contrast study
Barium Contrast study
High-osmolality water soluble (HOWS) contrast study
Low-osmolality water soluble (LOWS) contrast study.
 Radionuclide studies
7

8. Chest radiograph
 Anteroposterior (A/P) view:
Identification of heart and lung disease
To see the position of ET tube & other lines
 Identifiction of air leak syndrome.
 Cross-table lateral view:
To see the lung tube position - anteriorly or posteriorly
8

9.  Lateral decubitus view:
 For small pneumothorax or small fluid collection
 Upright view:
 To see free air under the diaphragm
Chest radiograph
9

10. 10

11. 11

12. 12

13. Indications of CXR
For initial diagnosis of the cause of respiratory distress
To Check the position of lines and tubes
Monitoring progression and responses to treatment
In case of respiratory deterioration
13

14. Normal CXR
Translucent
Air bronchogram can be present till 2nd generation of bronchi
in the retrocardiac area
Diaphragm- upto 6th rib anteriorly and 8th rib posteriorly
The normal cardiothoracic ratio can be as large as 60 percent
Residual lung fluid may give appearance of diffuse
opacification during first 4 hours of life
14

15. Normal chest x-ray of a two-hour-old newborn
15

16. Anatomical diagram of the anterior view of the lungs
16

17. 17

18. Assessment of the Quality
Projection – PA or AP view
Breath : Inspiration or Expiration
Position
Rotation
Penetration/exposure
Artifact
18

19. Projection
19

20. 20

21. Penetration
Intervertebral disc can be seen through the heart
If you see them very clearly the film is over-penetrated
If you do not see them it is underpenetrated
21

22. Good Penetration
22

23. Over penetration
Under penetration
23

24. Rotation
24

25. Well-aligned
Heart size exaggerated Heart size- small
Heart size- normal
25

26. Inspiratory Film Clues
• Diaphragm domes are
rounded
• 5th or 6th anterior rib
crosses the diaphragm on the
frontal film
• Lungs are black
Expiratory Film Clues
• Diaphragms are very domed
• 3rd or 4th anterior rib crosses
the diaphragm
• Lungs are white
Inspiration or Expiration
26

27. Evidences of hyperinflation
Lung expansion > 6 ribs
anteriorly, > 8 ribs posterioly
Flattening of diaphragms
Ribs are more horizontal
27

28. Cardio-thoracic ratio
 >50% is considered abnormal
in an adult; more than 60% in a
neonate.
AP views make heart appear
larger than it actually is
28

29. The thymus
The thymus is radiologically
characterized by a widening
of the upper mediastinum,
above the cardiac image
29

30. Notch-sign- where the inferior border of the normal
thymus blends with the border of the cardiac silhouette
Wave-sign- corresponding to a gentle undulation on
the thymus surface produced by costal arcs
compression, more frequently to the left
Sail sign- resulting from a peculiar shape of the thymus
appearing like a normal anterior mediastinal sail
shaped structure, more frequently to the right
The thymus
30

31. Notch-sign
31

32. A still open arterial canal
may be seen on a chest
x-ray as a convex
prominence to the left
of the spine, between
T3 and T4 vertebras
Ductus bump
32

33. skinfolds- projected
over the thoracic cavity,
and may simulate
pneumothorax
Artifacts
33

34. Chest x-ray findings of Common
disease in Newborn
34

35. Respiratory distress syndrome (RDS)
Fine, diffuse reticulogranular pattern
Air bronchograms
Low lung volume
Ground glass opacities
Whiteout lung
These radiographic findings are usually present
shortly after birth but they also may appear after
12-24 hours
35

36. Respiratory distress syndrome (RDS)
36

37. 37

38. Radiological grading
Grade I: good lung expansion,
fine reticulogranular mottling
Grade II: mottling with air bronchogram
Grade III: diffuse mottling, heart borders
just discernible, prominent air
bronchogram
Grade IV: bilateral confluent
opacification (white out)
38

39. Chest X Ray of RDS
39

40. Transient tachypnea of the newborn (TTN)
Symmetric perihilar and interstitial streaky infiltrates
Hyperinflation
Flattening of diaphragm
Prominence of the minor fissure
Small pleural effusion
Mild cardiomegaly
40

41. TTN
Plain chest radiograph
reveals overaerated lungs
with radiating streaky
densities from the hilum
to the peripheral lungs
bilaterally. Right minor
fissure is accentuated
41

42. TTN
42

43. Pneumonia
Diffuse alveolar or interstitial disease that is usually
asymmetric and localized
Pneumatoceles - staphylococcal pneumonia
Pleural effusions or empyema- bacterial pneumonia
Group B streptococcal pneumonia can appear similar to
respiratory distress syndrome (RDS)
43

44. Diffuse increase in interstitial
lung markings is typical with
neonatal pneumonia
Pneumonia
44

45. Staphylococcus aureus pneumonia.
Multifocal irregular opacities are
observed in both lungs with
cavitations (small arrows). Right
pleural effusion (long arrow) is
evident obliterating right
costophrenic sulcus
Pneumonia
45

46. 46

47. Meconium aspiration syndrome (MAS)
Bilateral, patchy, coarse infiltrates
Hyperinflation of the lungs
Flattened diaphragm
Increased incidence of pneumothorax
47

48. Meconium aspiration syndrome (MAS).
Chest radiograph showing diffuse
coarse increase in lung markings
accompanied by hyperinflation,
typical for meconium aspiration
syndrome (MAS)
48

49. Bronchopulmonary dysplasia (BPD)
The radiographic appearance is highly variable-
Fine, hazy appearance of the lungs
Mildly coarsened lung markings
Coarse, cystic lung pattern
49

50. Bronchopulmonary dysplasia (BPD)
Chest radiograph showing a
diffuse, moderately coarse
increase in lung density,
which in a 2-month-old
ventilated ex-preemie is most
consistent with
bronchopulmonary dysplasia
50

51. Bronchopulmonary dysplasia (BPD)
51

52. 52

53. Air surrounds the heart,
including the inferior
border
Pneumopericardium
53

54. AP view. A hyperlucent rim of air is
present lateral to the cardiac border
and beneath the thymus, displacing
the thymus superiorly away from
the cardiacsilhouette (“angel wing
sign”)
Pneumomediastinum
54

55. Left tension pneumothorax as shown
on an anteroposterior chest
radiograph in a ventilated infant on
day 2 of life. Note the accompanying
collapse of the left lung, depression of
the left diaphragm, and contralateral
shift of mediastinal structures
Tension pneumothorax
55

56. Congenital Diaphragmatic Hernia
Herniation of bowel
loops into the left
hemithorax, with a
shift of the heart and
mediastinum to the
right side.
56

57. Eventration of Diaphragm
Raised left dome of the
diaphragm, with well
defined left diaphragmatic
margin.
57

58. Cystic adenomatoid malformation
large air filled thin walled
cyst in the right lung with
herniation of the lung to
the contralateral side
58

59. Esophageal atresia with distal TEF
59

60. x-ray with contrast in the
upper esophagus showing
atresia
60

61. Contrast esophagogram
showing an isolated
tracheoesophageal fistula
(H-type) with contrast
material delineating the
trachea.
61

62. Radiological findings of Common
Cardiac disease
62

63. Boot shaped heart in TOF
63

64. Egg on side in transposition of great artery
64

65. Box shaped heart in ebstain anomaly
65

66. Position of Tubes and Catheters
 Endotracheal tubes (ETT)
 Nasogastric tubes (NGT)
 Umbilical venous catheters
 Umbilical arterial catheters
 Central venous lines
66

67. Naso/orogastric tube
The naso/orogastric tube
tip should be in the mid-
stomach
Naso/orogastric tube
67

68. Normal position- Halfway
between the thoracic inlet
(Medial ends of clavicles)
and the carina (4th
thoracic vertebra)
Endrotracheal tube
68

69. Endotracheal tube is
positioned in the oesophagus.
Chest radiograph shows
dilatation of the esophagus and
stomach, that are filled with air
69

70. Right bronchus intubation
with atelectasis of the
entire left lung.
70

71. The endotracheal tube (ETT) tip is
in the bronchus intermedius.
RUL will also become atelectatic
along with all of left lung
71

72. Normal- Venous umbilical
catheter localized in the
inferior vena cava at T8-T9
level
Umbilical venous catheter
72

73. Malpositioned umbilical
venous catheter (UVC). The
tip is malpositioned in the
region of left upper
pulmonary vein across the
patent foramen ovale.
73

74. Umbilical vein line
positioned in the periphery
of the liver through the
right portal vein.
74

75. The umbilical vein line
is positioned in the
umbilical vein and not
deep enough.
75

76. The umbilical arterial catheter
76

77. Low UAC- The tip should be below
the third lumbar vertebra,
optimally between L3 and L4
The umbilical arterial catheter
77

78. High-localization of arterial
umbilical catheter (arrow), the tip
should be between thoracic
vertebrae 6 and 9
The umbilical arterial catheter
78

79. Malposition of umbilical artery line,
folded in the abdominal aorta.
79

80. Deep position of umbilical
artery line, in aortic arch.
80

81. Malposition of umbilical artery
line in left iliac artery.
81

82. 82

83. 83

84. 84

85. Abdominal radiographs
85

86. Viewes
1. AP view- best view for diagnosing
 Intestinal obstruction
2. Cross-table lateral view-
Helps diagnose abdominal perforation
3. Left lateral decubitus view- Best for diagnosis of
intestinal perforation
86

87. Viewes
87

88. Cross-table lateral view-
88

89. Left lateral decubitus view
89

90. Normal Abdominal x-ray
11th rib
Hepatic flexure
Gas in
stomach
T12
Gas in caecum
Iliac crest
Femoral head
SI joint
Gas in sigmoid
Transverse colon
Splenic flexure
Psoas margin
Sacrum
Left kidney
Liver
Bladder
90

91. Gas pattern
• Stomach
– Almost always air in stomach
• Small bowel
– Usually small amount of air in
2 or 3 loops
• Large bowel
– Almost always air in rectum
and sigmoid
What is normal?
91

92. Normal Abdominal Gas Pattern
1. Air in the stomach- within 30 minutes after delivery.
2. Air in the small bowel- seen by 3–4 hours of age.
3. Air in the colon and rectum- seen by 6–8 hours of
age
92

93. Normal fluid levels
• Stomach
– Always (upright, decub)
• Small bowel
– Two or three levels
acceptable (upright, decub)
• Large bowel
– None normally
93

94. Large vs small bowel
• Large bowel
– Peripheral
– Haustral markings don’t extend from wall to wall
• Small bowel
– Central
– Valvulae conniventes extend across lumen
94

95. 95

96. Differs from that of older children
 A neonates has less fat- the outlines of organs such as
the kidneys and psoas muscles are not as well defined
No mucosal folds- cannot differentiate small bowel gas
from large bowel gas
The position of the bowel gas- helps us to
differentiate small bowel from large bowel
96

97. Normal plain abdominal film of a newborn
97

98. Findings of Common disease in
Newborn on plain abdominal X-ray
98

99. Intestinal obstruction
Gaseous intestinal distention
Gas may be decreased or absent distal to the
obstruction.
Air-fluid levels are seen proximal to the
obstruction.
99

100. level of obstruction
•Duodenal atresia- if only stomach and loop of
intestine is dilated in the right upper quadrant then
duodenal atresia is likely.
• Jejunal atresia- Dilated loops confined to left upper
part of abdomen
• Ileal artresia- Many dilated loops occupying
mainly the right side of spine
100

101. Small bowel obstruction
101

102. Large bowel obstruction
102

103. Duodenal atresia
Double bubble sign-
with gas filled distended
stomach and duodenum
with an absence of
distal gas
103

104. Plain abdominal radiograph of newborn
reveals dilated gastric bubble and massively
dilated duodenum and proximal jejunum with
gasless abdomen distal to level of obstruction;
these findings are consistent with jejunal
atresia.
Jejunal atresia
104

105. Ileal Atresia
Multiple air-fluid levels
proximal to the point of
obstruction, and absent
gas distal to the
obstruction
105

106. Hirschsprung disease
Findings are primarily
those of a bowel
obstruction
The affected bowel is of
smaller calibre variable
amounts of colonic
distension are present
106

107. Meconium Ileus
Dilated bowel loops
proximal to the impaction.
Classically, there is a paucity
or absence of air-fluid levels
and a "bubbly" appearance of
the distended intestinal loops
on radiographs.
107

108. Necrotizing Enterocolitis
Abnormal gas pattern, ileus
Bowel wall edema
Pneumatosisintestinalis
Fixed position loop
Portal venous gas
Pneumoperitonium
108

109. distension of small bowel loops.
Necrotizing Enterocolitis
109

110. Pneumatosis intestinalis is
the classic radiographic
finding in NEC
Necrotizing Enterocolitis
110

111. Portal venous gas (arrow)
Necrotizing Enterocolitis
111

112. NEC with perforation
Necrotizing Enterocolitis
112

113. Area of lucency over the right
hemi-diaphragm obliterating
the normal opacity of the liver
in a neonate with perforation
GIT perforation
113

114. Contrast studies
Types of Contrast agent
1. Iodinated
1 Ionic
2 Non-ionic
2. Barium
3. Air
4. Carbon dioxide
114

115. Barium contrast studies
Barium sulfate-
Inert compound
Water-insoluble
Not absorbed from the GI tract
115

116. Barium contrast studies
Indications
GI tract imaging
Barium swallow -used to study the pharynx and
esophagus
Barium meal- used to study the lower esophagus,
stomach and duodenum
Barium follow through - used to study the small intestine
Barium enema- used to study the large intestine and
rectum
Suspected H-type TEF
Suspected esophageal perforation
Suspected gastroesophageal reflux (GER).
116

117. High-osmolality water-soluble (HOWS)
contrast studies
Formerly widely employed in imaging
HOWS contrast agents have been replaced by LOWS
117

118. Low-osmolality water-soluble (LOWS)
contrast agents.
Advantages-
a. Do not cause fluid shifts.
b. If bowel perforation is present- nontoxic to the peritoneal
cavity
c. If aspirated, there is limited irritation to the lungs.
d. Limited absorption from the normal intestinal tract
Disadvantages- higher cost than barium.
118

119. Commonly used contrast agents
Omnipaque – Iohexol
Iopamiro- iopamidol
119

120. Preparation for radiologic studies
Neonatal study Preparation
Upper GI series NPO for 1-2 hours for neonate & infants upto 2 year
Contrast enema No preparation needed for evaluation of bowel
obstruction or to rule out Hirschsprung disease
HIDA(Hepatobiliary)
scan
Oral phenobarbitone (5 mg/kg /day) for 5 days prior
to examination
Voiding
cystourethrogram
(VCUG)
No preparation
120

121. Findings of Common disease in
Newborn on Contrast X-ray
121

122. Congenital hypertrophic pyloric stenosis
122

123. String sign
Shoulder sign
Double-track sign
Congenital hypertrophic pyloric stenosis
123

124. Duodenal atresia
Upper GI contrast study demonstrates
dilated stomach and proximal duodenum
without further passage of contrast in
newborn with duodenal atresia.
124

125. Plain abdominal radiograph of newborn
reveals dilated gastric bubble and
massively dilated duodenum and
proximal jejunum with gasless abdomen
distal to level of obstruction; these
findings are consistent with jejunal
atresia.
Jejunal atresia
125

126. Upper GI contrast study demonstrates
dilated stomach and duodenum, with
enlarged upper jejunum and lack of
passage of contrast agent to distal small
bowel; these findings are consistent with
high jejunal atresia.
Jejunal atresia
126

127. Ileal Atresia
Multiple air-fluid levels
proximal to the point of
obstruction, and absent
gas distal to the
obstruction
127

128. Lower GI contrast study in
newborn with ileal atresia
demonstrates microcolon with
dilated non-contrast-enhanced
stomach and proximal small
bowel.
Ileal atresia
128

129. Malrotation with volvulus
129

130. malrotation without
midgut.
Note the small bowel
in the right abdomen.
Malrotation without midgut volvulus
130

131. The abdominal plain film
is usually nonspecific but
might demonstrate a
gasless abdomen or
evidence of duodenal
obstruction with a
double-bubble sign.
Malrotation with midgut volvulus
131

132. Corkscrew sign in a patient
with intestinal malrotation
with volvulus
Malrotation with midgut volvulus
132

133. Meconium Ileus
Dilated bowel loops
proximal to the impaction.
Classically, there is a paucity
or absence of air-fluid levels
and a "bubbly" appearance of
the distended intestinal loops
on radiographs.
133

134. Gastrografin enema study shows filling
defects in the terminal ileum and
cecum. Also note the microcolon
(transverse and descending colon).
134

135. Hirschsprung disease
Findings are primarily
those of a bowel
obstruction
The affected bowel is of
smaller calibre variable
amounts of colonic
distension are present
135

136. Barium enema showing
reduced caliber of the rectum,
followed by a transition zone
to an enlarged-caliber sigmoid.
Hirschsprung disease
136

137. Baby held upside down for 3-
5 minutes and then lateral X-
ray is taken
Invertogram
137

138. Invertogram
138

139. Cross Table Prone Lateral X-Ray
139

140. 140

141. 141

142. Low- When a rectal pouch that is below the I line
Intermediate- If the rectum ends below the P–C
line, but not below the I line
 High- when pouch ends above the P–C line
Invertogram
142

143. 143

144. 144