Monica Epelman

• MD
• Chair at Nemours Children's Hospital, Orlando, FL

Right lower quadrant (RLQ) pain is a common clinical presentation in children, and accurate clinical diagnosis remains challenging given that this nonspecific presentation is associated with numerous surgical and nonsurgical conditions. The broad differential diagnosis varies by patient age and sex. Importance considerations in selection of a diagn...

Primary intratesticular tumors are uncommon in children, but incidence and risk of malignancy both sharply increase during adolescence. Ultrasound is the mainstay for imaging the primary lesion, and cross‐sectional modalities are often required for evaluation of regional or distant disease. However, variations to this approach are dictated by addit...

Ovarian tumors in children are uncommon. Like those arising in the adult population, they may be broadly divided into germ cell, sex cord, and surface epithelium subtypes; however, germ cell tumors comprise the majority of lesions in children, whereas tumors of surface epithelial origin predominate in adults. Diagnostic workup, including the use of...

Chondroblastoma is a locally destructive, cartilaginous bone tumor that accounts for a small percentage of cases of primary bone tumors. Although considered a benign tumor, chondroblastoma can locally recur and can rarely metastasize. Here, we report a rare presentation of a locally recurrent chondroblastoma with pulmonary metastases. A 13-year-old...

Soft-tissue lumps and bumps are a common referral for imaging in children and adolescents. The etiology of these lesions includes benign non-tumorous lesions, as well as benign and malignant tumors. Some of these lesions have a characteristic imaging appearance but others do not and require tissue sampling to make a diagnosis. MRI typically provide...

Female Müllerian anomalies are the result of failure of formation, fusion or resorption of the Müllerian ducts and are relatively common, with a prevalence of 5.5–7.0% in the general population. While some of these anomalies are asymptomatic, those presenting with obstruction require accurate identification for optimal clinical management including...

Contrast-enhanced voiding urosonography (ceVUS) is a well-established, sensitive and safe ultrasound (US) modality for detecting and grading vesicoureteral reflux (VUR) and urethral imaging in children. Nearly three decades of remarkable advances in US technology and US contrast agents have refined ceVUS’s diagnostic potential. The recent approval...

Introduction The natural history of asymptomatic nephrolithiasis (AN) in children is not well defined. Furthermore, there is no guidance on the utility of repeated renal ultrasound evaluations in this same population. Follow-up ultrasound studies are often obtained as frequently as every 6 months. The goal of this study is to assess the follow-up u...

We present a case of a pediatric patient with congenital unfused anterior and posterior arches of the atlas (C1), also known as bipartite atlas, who sustained a traumatic injury during gymnastics. A computed tomography (CT) scan of the cervical spine raised concern for abnormal separation of the midline cleft of the anterior arch of C1. Subsequent...

Osteosarcoma is a malignant bone tumor most commonly presenting in children. It has a bimodal distribution with a peak incidence occurring during the ages of 10-14 years old and in adults greater than age 65. The first peak of osteosarcoma correlates with the increased proliferation of bone during the pubertal growth period. Osteosarcoma most frequ...

Individuals with Neurofibromatosis I may develop plexiform neurofibromas throughout the body, however they are rarely seen in the pelvis. We present a 15-year-old patient with NF1 with a large unresectable neurofibroma located between the prostate and bladder discovered incidentally on renal/bladder ultrasound during the evaluation of bowel/bladder...

Background While typical patterns of osteoid osteoma have been described on CT, MRI findings can overlap among different diseases, and atypical patterns exist. In this study, we assessed the presence of a novel dark rim sign and its utility in the MRI diagnosis of osteoid osteoma.Objective The purpose of this retrospective study was to assess the u...

OBJECTIVE. Pediatric CT angiography (CTA) presents unique challenges compared with adult CTA. Because of the ionizing radiation exposure, CTA should be used judiciously in children. The pearls offered here are observations gleaned from the authors' experience in the use of pediatric CTA. We also present some potential follies to be avoided. CONCLUS...

The differential diagnosis of scrotal pain and swelling in adolescent males includes testicular and appendage torsion, epididymitis, epididymo-orchitis, trauma and incarcerated hernia. Physical examination, ultrasound and urinalysis often can identify the etiology of the scrotal pain and swelling. We present a case of left scrotal pain and swelling...

Osteoid osteoma (OO) is a benign bone neoplasm consisting of a central prostaglandin-secreting nidus surrounded by a zone of reactive sclerosis. The diagnosis is suspected in teenagers and young adults with longstanding nighttime pain that is relieved by salicylates or nonsteroidal anti-inflammatory drugs. Early studies suggested that CT had a high...

Transabdominal ultrasound remains the first-line imaging modality of the pediatric female pelvis. However, magnetic resonance imaging (MR imaging) is increasingly important in the investigation and characterization of suspected abnormalities. The superior soft tissue contrast resolution of MR imaging provides excellent evaluation of ovarian and ute...

Leclercia adecarboxylata is a gram-negative bacillus of the Enterobacteriaceae family. It is a rare human pathogen that is often acquired via wound and/or contact with aquatic environment. Although multiple cases of L. adecarboxylata infections are described in the adult population, few have been documented in pediatrics. We will present two cases...

Although perforated appendicitis in pediatric patients can result in a diverse array of complications, scrotal abscess is a rarely documented phenomenon. We present a case of acute scrotum after laparoscopic appendectomy. A retrospective review of prior literature on scrotal abscess secondary to perforated appendicitis was performed via PubMed to r...

Cystic dysplasia of the rete testis (CDT) is a rare, benign, cause of testicular mass in the pediatric population. The mass appears on sonography as multiple small cysts of varying size surrounded by normal or compressed testicular tissue. CDT is often associated with other genitourinary anomalies, commonly presenting with agenesis or dysplasia of...

OBJECTIVE. Pediatric CT angiography (CTA) can be useful for assessing numerous congenital and acquired disorders. This article discusses common pediatric applications of thoracoabdominal CTA, including for congenital pulmonary airway malformation, sequestration, vascular rings, aortic coarctation, pulmonary embolism, nontraumatic hemorrhage, abdomi...

Williams syndrome is a multisystem, congenital disorder which is commonly associated with arterial stenoses: supravalvar aortic stenosis and peripheral pulmonary artery stenosis. Venous abnormalities have not been previously reported in children with Williams syndrome. We present a case of a 3-year-old girl with Williams syndrome and diffuse venous...

Renal masses in the pediatric population carry a wide differential diagnosis; however, a careful history and physical can often elucidate the source. Infectious, benign, and malignant causes should all be considered in a patient presenting with a renal mass to mitigate risks of treatment options and safely ameliorate the patient's pathology. Pediat...

Carpal coalitions are congenital segmentation anomalies with an abnormal union of one or more carpal bones. They can be broadly classified as osseous or non-osseous and as partial or complete. Lunotriquetral coalitions are the most common type of carpal coalition and are typically asymptomatic and detected incidentally. However, there are several c...

Background Heterotaxy refers to the abnormal arrangement of organs across the left–right axis and is typically associated with complex cardiovascular malformations. Objective To characterise the range of cardiac and extracardiac CT angiography findings in children with heterotaxy using the latest nomenclature consensus and to compare the different...

Inverted-Y ureteral duplication is one of the rarest anomalies of ureteral branching, which has been found to be more prevalent in females. ² Females commonly present with urinary incontinence often associated with distal limb ectopia to the bladder neck, uterus, or vagina. ² We present the case of a 7-year-old female with intermittent urinary inco...

AMAÇ: Üç ana tip konjenital akciğer lezyonunun hacim ve büyüme oranlarının karşılaştırılması, hacim ölçümünün lezyon karakterizasyonundaki etkinliğinin tanımlanması amaçlanmıştır. GEREÇ VE YÖNTEM: Çalışmamızda patolojik olarak kanıtlanmış konjenital akciğer hastalığı olan 59 infant (0-101 gün) retrospektif olarak değerlendirildi. Görüntüleme yöntem...

Caroli syndrome, which is characterized by saccular and fusiform dilatation of the biliary ducts, is usually observed in association with autosomal recessive polycystic kidney disease (ARPKD). Although the diagnosis of ARPKD is generally easy to make in postnatal ultrasound, the diagnosis of Caroli syndrome may be challenging in prenatal ultrasound...

A dropped appendicolith is a well-known complication of laparoscopic appendectomy that may occur because of stone expulsion from the appendix, before or during surgery, and typically manifests as a focal, subcentimeter area of high attenuation with or without associated abscess. Dropped appendicoliths may act as niduses for infection and may result...

Objective: The purpose of this article is to discuss advances in imaging and diagnosis of skeletal dysplasias. Conclusion: Skeletal dysplasias are a heterogeneous group of disorders affecting bone and cartilage and characterized by abnormal shape, growth, and integrity of the skeleton. These disorders may be inherited in a multitude of genetic p...

Non-catheter-related venous thromboembolism (VTE) is less common in children than in adults. Although the presence of a central venous catheter is the most common cause of venous thrombosis in children, infection and inflammation, malignancy, hypercoagulability, dehydration, and certain sites of normal variant and pathologic anatomic narrowing all...

A thyroid nodule detected clinically or incidentally at medical imaging is a common indication for ultrasonography (US) in the adult population. This scenario is less frequently the case in pediatric patients, and the approach to evaluation of thyroid nodules deserves modification in these patients because of the increased probability of malignancy...

Ultrasound is the primary imaging modality of the pediatric female pelvis and is often requested to evaluate girls with pelvic or abdominal pain or abnormal bleeding. The US interpretation can help guide the clinician toward medical or surgical management. Here we discuss the normal US anatomy of the female pelvis and illustrate, through case examp...

The wide availability of ultrasound, along with its lack of ionizing radiation burden and need for sedation for most exams, often make sonography the first line in the imaging evaluation of children. The developing osseous anatomy of the spine in young infants provides a distinct window allowing for a detailed depiction of the spinal canal and its...

Chest ultrasonography is an important imaging adjunct for diagnosing and managing disease in children. Compared with CT and MRI, ultrasound is cheaper, portable and provides vascular or flow-related information that cannot otherwise be obtained noninvasively. The spatial and temporal resolution of ultrasound is excellent, particularly for superfici...

Background: Juvenile localized scleroderma comprises a group of autoimmune conditions often characterized clinically by an area of skin hardening. In addition to superficial changes in the skin and subcutaneous tissues, juvenile localized scleroderma may involve the deep soft tissues, bones and joints, possibly resulting in functional impairment a...

BackgroundCT angiography is gaining broader acceptance in the evaluation of children with known or suspected congenital heart disease. These studies include non-cardiovascular structures such as the mediastinum, lung parenchyma and upper abdominal organs. It is important to inspect all these structures for potential abnormalities that might be clin...

Background: To retrospectively determine the prevalence of intraventricular hemorrhage (IVH) in term neonates with hypoxic-ischemic encephalopathy (HIE) using head ultrasound (HUS) and MRI, and to compare the incidence of IVH in term babies with HIE treated by therapeutic hypothermia versus those managed conventionally. Methods: A total of 61 te...

Transabdominal US remains the primary screening imaging modality of the pediatric female pelvis. However, MRI has become an invaluable adjunct to US in recent years. MRI offers superb soft-tissue contrast resolution that allows for detailed evaluation, particularly of the ovaries and their associated pathology. MRI can yield diagnostic information...

Background: The prenatal evaluation of skeletal dysplasias is challenging. Ultrasound (US) has limited sensitivity in evaluating these abnormalities. Low-dose fetal computed tomography (CT) is a helpful adjunct in evaluating the fetus with severe abnormalities, but its use is limited by lack of data on normal fetal bone length. Objective: To obt...

Background: We report the radiologic findings of herniation of Hoffa's fat pad through a defect in the lateral patellar retinaculum in young children who presented with painless masses visible by ultrasound (US) only with flexion of the knee. Material and methods: Six children, between the ages of 1-8 years, presented with an anterolateral knee...

Radiology of the airways in newborns and infants is challenging due the small size of their anatomy, their inability to follow breathing instructions, and the concern for long-term effects of radiation exposure. While some patients can be managed with observation or empiric therapy, for other patients the diagnosis may remain uncertain, and imaging...

This article emphasizes technical factors that are helpful for optimizing sonographic examinations of the brain in preterm and term neonates. It also reviews existing data regarding the accuracy of neurosonographic examinations relative to MR. Many neurosonographic signs are subtle and can be easily overlooked, which could lead to delayed diagnosis...

Background: Progressive hepatic fibrosis is common after the Fontan operation, but little is known about its onset. We sought to determine whether hepatic abnormalities before the Fontan operation, and whether further abnormalities can be identified soon afterward. Methods: Patients undergoing the Fontan operation at our institution were prospec...

Vascular rings can be challenging to diagnose because they can contain atretic portions not detectable with current imaging modalities. In these cases, where the compressed airway and esophagus are not encircled by patent, opacified vessels, there are useful secondary signs that should be considered and should raise suspicion for the presence of a...

Figure 1. Normal placenta. Sagittal (A) and axial (B) single-shot fast spin-echo (SSFSE) T2-weighted MR images of a placenta at 20 weeks of gestation in 2 different patients show the normal, homogeneous placental signal that is hypointense to isointense relative to the surrounding myometrium. Note the relatively well-defined hypointense line at the...

Developmental anomalies of the uterus and the vagina are associated with infertility and miscarriage and are most commonly detected in the postpubertal age-group. These conditions may also present in younger patients as a mass or pain owing to obstruction of the uterus or the vagina. Associated urinary tract anomalies are common, as well. Accurate...

Chest masses present a common problem in the perinatal period. Advances in prenatal ultrasound, supplemented by fetal magnetic resonance imaging (MRI), now allow early detection and detailed characterization of many thoracic lesions in utero. As such, in asymptomatic infants, assessment with postnatal computed tomography (CT) or MRI can often be de...

The imaging of vasculitis, vasculopathies, and other vascular disorders in neonates presents unique challenges compared with the vascular imaging of older children or adults. These challenges include small-caliber vessels, the need for sedation or anesthesia, a high rate of vasospasm, higher respiratory rates, and a greater susceptibility to long-t...

Button battery ingestion can lead to dangerous complications, including vasculoesophageal fistula formation. The presence of a vascular ring may complicate battery ingestion if the battery lodges at the level of the ring and its important vascular structures. We report a 4-year-old boy with trisomy 21 who was diagnosed with a vascular ring at the t...

Integration was implemented of previously independently practicing pediatric radiology services across a pediatric health care system with sites 1,000 miles apart. The purpose of this manuscript is to describe the process utilized to integrate imaging services across our enterprise and to study the direct effects on report turnaround time and other...

Objectives: Progressive hepatic fibrosis is common after the Fontan operation, but little is known about its onset. We sought to determine if there is non-invasive evidence of hepatic injury prior to the Fontan operation, and if further injury is seen soon after the procedure. Methods: Patients undergoing the Fontan operation at our institution wer...

Findings of neonatal encephalopathy (NE) and specifically the findings of hypoxic-ischemic injury (HII) are frequently evident on MRI. Although MRI has become more widely used and has gained widespread acceptance as the study of choice for the evaluation of NE in recent years, MRI costs are high, and access to MRI is sometimes limited for extremely...

With the implementation of prenatal screening with ultrasound (US) and, more recently, fetal magnetic resonance imaging (MRI), patterns of referral have changed. US remains the first-line imaging modality for evaluating the genitourinary system during the neonatal period, and may be enhanced with the use of focused, high-resolution linear images of...

Background: The sonographic (US) features of limb-body wall complex have been well documented; however the literature regarding the findings on MRI in limb-body wall complex is scant. Objective: To characterize the prenatal MRI features of limb-body wall complex. Materials and methods: We performed a retrospective review of all MRI scans of fe...

PURPOSE/AIM Evaluation of the fetus with presumed skeletal dysplasia (SD) is difficult because of the rarity of each disorder, the multitude of differential diagnosis for the encountered findings and the lack of precise molecular diagnosis. The sensitivity of US, the main imaging technique in obstetrics, is 40-60%. Low-dose fetal CT is a helpful im...

The hemoglobinopathies are a group of genetic disorders with a broad spectrum of clinical manifestations and radiologic findings. The imaging of pediatric hemoglobinopathies, which is influenced by concomitant hemosiderosis and the sequela of chelation therapy, has evolved over the years along with ever-improving technology. This article reviews an...

Together, leukemia and lymphoma account for half of all childhood malignancies. Leukemia and lymphoma arise from similar cell lines and can have overlapping imaging features; however, the clinical presentation, imaging strategies, and treatment protocols can vary substantially based on the specific subtype. Although imaging does not play a central...

The differential diagnosis of renal masses in pediatric patients includes benign and malignant tumors, as well as nonneoplastic mass-like lesions mimicking tumors. Although the spectrum of renal masses in children has some overlap with that of adults, it is important to understand the renal pathologic processes specific to the pediatric population,...

Duplex renal collecting systems are common congenital anomalies of the upper urinary tract. In most cases they are incidental findings and not associated with additional pathologies. They demonstrate, however, higher incidences of hydroureteronephrosis, ureteroceles, and ectopic ureters. The most comprehensive morphologic and functional evaluation...

Although many Müllerian duct anomalies do not require treatment, surgical intervention is sometimes necessary to enable sexual activity or to preserve fertility. The identification of these anomalies is important for optimal clinical management or surgical treatment. Magnetic resonance (MR) imaging is a robust method for adequately evaluating and c...

Replaced right hepatic artery is a well-described normal anatomical variant, not previously associated with acute or chronic abdominal symptoms or long-term sequelae. We report a 15-year-old girl presenting with nearly a decade of symptoms secondary to external compression of the proximal duodenum by the ventral passage of a replaced right hepatic...

The inguinal canal is often seen at the edge of the field of view on plain radiography, computed tomography, or magnetic resonance imaging and may often not be scanned when performing sonography of the scrotum or abdomen. As a result, pathology in this anatomical region may be easily overlooked. The peculiar embryology of the inguinal canal makes t...

Background Abdominal radiography is the reference standard in imaging neonates with necrotizing enterocolitis (NEC); however, ultrasound of the abdomen including bowel may be of value in this setting. Objective To correlate sonographic and radiographic findings with patient outcomes in NEC. Materials and methods We reviewed sonographic and radiogra...

Congenital thoracic vascular anomalies may involve the thoracic aorta and its branches, pulmonary arteries and veins, as well as the thoracic systemic veins. Technical improvements in multidetector-row computed tomography (MDCT) and magnetic resonance imaging (MRI), now allow for the noninvasive preoperative and postoperative imaging evaluation of...

Objective: Prenatal diagnosis of skeletal dysplasia is often difficult and based on findings with ultrasound, a technique with 40-60% sensitivity. The purpose of this study was to evaluate a preliminary experience in assessing severe prenatal osseous abnormalities with low-dose fetal CT. The hypothesis was that use of CT may improve the prenatal d...

Timely and accurate airway assessment is essential in infants and children who present with respiratory distress. With smaller and more compressible airways than their adult counterparts, more prone symptomatic airway obstruction. Failure to promptly recognize and treat airway disease can lead to substantial short-term morbidity or even mortality a...

Genitourinary imaging has evolved along with the ever improving technology, in addition, our pattern of referrals has changed, with most neonates being presently asymptomatic and their examinations being prompted by prenatally detected abnormalities. Ultrasonography dominates in this domain because of the combination of the excellent demonstration...

Historically, the evaluation of renovascular hypertension has been accomplished by US, renal scintigraphy and digital subtraction angiography. Based on its high accuracy reported in adults renal CT angiography (CTA) with pediatric-appropriate low radiation dose techniques has become an important tool in the workup of renovascular hypertension in ch...

PURPOSE/AIM 1. To illustrate important US findings to help in the diagnosis of hypoxic-ischemic injuries (HII) and to correlate these with MRI. 2. To learn and illustrate optimal methods and techniques to depict HII findings on sonography (US). CONTENT ORGANIZATION In the authors’ experience, the head US findings associated with HII may be divided...

Osteoid osteoma is a common benign bone-forming lesion that is composed of a nidus of vascular osteoid tissue and woven bone lined by osteoblasts. It is frequently associated with considerable surrounding inflammation. The diagnosis is usually straightforward when imaging reveals a radiolucent nidus surrounded by variable degrees of reactive sclero...

Tuberous sclerosis complex (TSC) is an autosomal dominant disorder in which benign hamartomas develop in multiple organ systems. Increasingly, stigmata of the disease, such as cardiac rhabdomyomas, are detected on routine prenatal ultrasound. Such a finding should prompt additional imaging studies in order to confirm diagnosis and to identify poten...

Objective: The objective of this article is to present the fetal MRI patterns of complex genitourinary abnormalities including epispadias-exstrophy complex, cloacal malformation, urogenital sinus anomaly, posterior urethral valves, and other causes that result in lower urinary tract dilatation without oligohydramnios. Relevant embryology will be r...

Objective: The objective of this article is to illustrate the imaging features of patients with extrahepatic portal venous obstruction who are evaluated before or after a Rex shunt surgery. Conclusion: The Rex shunt is a potentially curative surgical procedure that reestablishes physiologic hepatopetal portal flow. It is typically accomplished b...

Historically, the evaluation of the pediatric chest has been accomplished via CT and conventional radiography. Our objective is to discuss and illustrate the role of US as a non-ionizing radiation alternative in the evaluation of the pediatric chest. US is a valuable tool in the evaluation of the pediatric chest. It can be used as a first-line moda...

The advent of prenatal US and, more recently, fetal MRI has changed our pattern of referrals. In the current clinical algorithms, most neonates evaluated for genitourinary abnormalities are asymptomatic. These infants are referred for multidisciplinary consultation, imaging and surveillance. Evaluation of these children commences following pertinen...

Congenital skeletal abnormalities compose a heterogeneous and complex group of conditions that affect bone growth and development and result in various anomalies in shape and size of the skeleton. Prenatal sonographic diagnosis of these anomalies is challenging because of the relative rarity of each skeletal dysplasia, the multitude of differential...

Magnetic resonance (MR) imaging is superior to ultrasonography (US) for the evaluation and prognostication of neonates with neonatal encephalopathy (NE). Nonetheless, US may provide important information early in the course of NE and can be used to document the evolution of lesions. This article provides an overview of useful findings in the US eva...

The clinical and radiological examinations are the foundation of medical investigation of the acutely ill neonate. The proper use and interpretation of radiological studies requires teamwork and clear communication between the clinicians (including the obstetricians and surgeons, as appropriate) and the radiologists. Some literature confirms that a...

Introduction Neonatal imaging of the central nervous system has progressed rapidly in the last few years, although ultrasound (US) imaging remains the mainstay of bedside investigation. However, with the increased availability of magnetic resonance imaging (MRI), its potential utility is increasing. We highlight the relative usefulness of the imagi...

Several newborn lung diseases present very similarly, whether in the preterm or the term infant. Varying combinations of tachypnea, apnea, nasal flaring, expiratory grunting, sternal or costal retractions, and a supplemental oxygen need or cyanosis are manifestations of “respiratory distress.” In the preterm infant, this usually results from surfac...

Introduction During pregnancy, routine imaging of the fetal kidney is usual, although it may be prompted by an abnormal amount of amniotic fluid. In the newborn, imaging is performed as follow-up to fetal findings or it is prompted by clinical indications. These include the following in the antenatal period oligohydramnios may signal onset of the P...

Vascular anomalies are congenital lesions that most often first present in pediatric patients. Treatment of these lesions is a multidisciplinary team approach, involving several specialties, including diagnostic and interventional radiology, dermatology, general and plastic surgery, otolaryngology, and hematology. Knowing the characteristic finding...

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