[Pathophysiology, diagnosis and therapy of three congenital dacryocystoceles]

BACKGROUND

Congenital dacryocystocele has been rarely described in German literature. Congenital obstruction and distention of the lacrimal sac makes it necessary to differentiate for various causes.

PATIENTS AND METHODS

Three infants had congenital dacryocystocele. The diagnosis was made by sonography and was established by probing the lacrimal duct and nasal endoscopy that showed a white prominent tumor below the lowest conch.

RESULTS

Directly after endonasal and canalicular opening of the dacryocystocele clear liquid with white detritus drained, and the swelling decreased. No further procedure was needed.

CONCLUSION

The diagnosis of dacryocystocele can be made by inspection, probing the lacrimal duct, ultrasound and nasal endoscopy. If probing of the lacrimal duct could not easily open the Hasner's membrane, endonasal opening can be performed. The cooperation with an ear-nose-throat specialist could lead to the diagnosis of dacryocystocele and sufficient treatment without the need for any further radiological examinations.

[Lipoma of the corpus callosum in a newborn infant: misinterpretation of cranial ultrasound by coincidence with thrombocytopenia]

Among the very rare intracerebral lipomas, those of the corpus callosum are the most frequent. Due to the advanced technology and the frequent use of ultrasonography these lesions are diagnosed more and more often. A female neonate was admitted to our hospital because of a progressive thrombocytopenia. Pregnancy was complicated by an autoimmune thrombocytopenia of the mother. While there were no remarkable findings on clinical presentation, a sonogram of the brain revealed an area of increased echogenicity in the midline which was interpreted as an intracerebral hemorrhage. In absence of any respective clinical signs a magnet-resonance-tomography of the brain was performed leading to the hypothesis of a lipoma of the corpus callosum (LCC) that could be verified by a densitometry in a cranial computer tomography (CT). Obviously, the initially performed sonogram was misinterpreted as an intracerebral hemorrhage due to the coincidence with the thrombocytopenia. At last the discrepancy of clinical and ultrasonographical findings led to the diagnosis by magnet-resonance-tomography and CT scan. Knowledge of the typical sonographic appearance of an LCC may be helpful for the differential diagnosis of this rare lesion even in fetal ultrasound.

MR imaging fails to detect bone marrow oedema in osteomyelitis: report of two cases

Bone marrow oedema is the earliest and most sensitive sign in diagnostic imaging of osteomyelitis. In the two demonstrated cases of acute and chronic osteomyelitis, MRI was not able to detect bone marrow oedema due to accompanying haemosiderosis and sclerosis surrounding a bone abscess.

[Intestinal infection, the most frequent cause of invagination in childhood: results of a 10-year clinical study]

BACKGROUND

Intussusception is the most common cause of an acute abdomen in early childhood. 90% of all intussusceptions were thought to be idiopathic, because no lead points could be evaluated.

PATIENTS

In our study we examined 148 children (93 boys and 55 girls) between 2. month and 18. years of age with 155 intussusceptions.

METHOD

Besides epidemiological features and patients history we determined systematically all symptoms which occurred since the beginning of sickness. We performed ultrasound examinations before and after hydrostatic reduction with each child in order to find pathologic lead points. Microbiologic stool examination could be carried out at 99 specimen.

RESULTS

41 of 155 children with intussusception (26.5%) showed a pathologic finding next to the intussusception, with 29 children (18.7%) suffering from mesenteric lymphadenitis. 60.6% of examined stool specimen were abnormal. The most common germs were adenovirus, yersinia and staphylococcus aureus. Abdominal pain was the main symptom and was found in 72.6% of all children. 21% suffered from the classic trias abdominal pain, vomiting and rectal bleeding. 21.9% had diarrhea and 18% fever and signs of inflammation as unspecific symptoms.

CONCLUSIONS

In our study we found mesenteric lymphadenitis as the most common lead point in intussusception. In conclusion with 60.6% pathologic germs in the examined stool specimen we assume gastrointestinal infection as the main cause of intussusception in childhood.

[Digital subtraction angiography with carbon dioxide using a new gas dosage system]

PURPOSE

The clinical evaluation of digital subtraction angiography with carbon dioxide using a newly developed low-tech CO2 dosage and injection system.

METHOD AND PATIENTS

The hand-held system (CO2 angio set) consists of a dosage chamber in connection with a special stopcock to apportion the gas. By optimising injection volume and pressure steady gas flow characteristics are approximated. A safety design prevents unintentional gas injection. CO2 arteriographies were performed on 185 patients. Main indications were renal insufficiency and a history of adverse reactions to iodinated contrast media. In patients with femoral cannula access, catheterless reflux angiography was performed.

RESULTS

The injection system provided complete and coherent visualisation of the abdominal aorta, visceral, pelvic, and lower limb arteries via catheter (71 cases) or via femoral cannula using reflux technique (114 cases). Stenoses, occlusions, and collaterals were assessable. Employing the gas reflux over the aortic bifurcation bilateral run-off studies up to the calf trifurcation were performed via unilateral femoral cannula. Use of a dedicated stacking software improved image quality of distal femoral, popliteal and calf arteries.

CONCLUSION

The CO2 management system allows adequate imaging of the arteries below the diaphragm. Ease and safety of use and low costs are advantageous.

Thoracic sequelae after surgical closure of the patent ductus arteriosus in premature infants

Thirty-six children (median chronological age 6 years 1 month) who had undergone surgical closure of a patent ductus arteriosus through a left posterolateral thoracotomy in the neonatal period (median gestational age 32 weeks) were investigated prospectively with respect to anatomical and functional changes of the chest. At follow-up examination, residual or recurrent patent ductus arteriosus was not observed. Three patients had chronic bronchial obstruction. Two patients showed pathological musculoskeletal thoracic sequelae that did not require any treatment at the time of follow-up; persistence of immediate postoperative left phrenic palsy (n = 1) and thoracic scoliosis (n = 1). Twenty of the 27 patients in whom chest X-ray was performed had minor radiological skeletal anomalies in the form of rib deformation or fusion related to the thoracotomy, lesions which have a potential to induce thoracic scoliosis. Left shoulder elevation at chest X-ray and isolated left arm dysfunction at clinical examination were not observed. Despite the low incidence of scoliosis and the absence of left arm dysfunction observed at mid-term follow-up in our series, the incidence of minor rib deformations with a potential to induce severe anomalies such as scoliosis should motivate late follow-up examination at adolescence to definitively assess the prevalence of thoracic sequelae after surgical closure of the patent ductus arteriosus in premature infants.

[Catheterization of the nasolacrimal duct]

A technique is described for passing a guide wire through the lacrimal duct into the nose following catheterisation of the duct. The wire is passed into the pharynx, a 7 F feeding tube is passed through the nose into the pharynx and these are then pulled out of the mouth with a Magill forceps. The tip of the feeding tube is then cut off and the guide wire introduced into a side hole of the catheter. By removing the catheter, the tip of the guide wire is pulled along and can be removed from the nose.

Inflammatory reaction and capillary leak syndrome related to cardiopulmonary bypass in neonates undergoing cardiac operations

We studied the inflammatory reaction related to cardiopulmonary bypass in 24 neonates (median age 6 days) undergoing the arterial switch operation for simple transposition of the great arteries, with respect to the development of postoperative capillary leak syndrome. Complement proteins, leukocyte count, tumor necrosis factor-alpha, and histamine levels were determined before, during, and after cardiopulmonary bypass. Additionally, protein movement from the intravascular into the extravascular space during cardiopulmonary bypass was assessed by the measurement of plasma concentrations of proteins with molecular weights ranging from 21,200 to 718,000. Capillary leak syndrome developed in 13 of the 24 neonates. Patients with capillary leak syndrome, as compared with those without, had preoperatively higher C5a levels (C5a, 3.0 +/- 0.6 microgram/L vs 0.9 +/- 0.2 microgram/L) (mean +/- standard error of the mean) (p < 0.05) and higher leukocyte counts (leukocytes, 17.9 +/- 2.1 X 10(3) cells/ml versus 11.7 +/- 0.8 X 10(3) cells/ml) (p < 0.05), suggesting in these neonates a preoperative inflammatory state. Preoperative clinical and operative data were identical in both patient groups. Before cardiopulmonary bypass, serum protein concentrations were similar in all patients. Ten minutes after institution of cardiopulmonary bypass, protein concentrations fell to significantly lower values in patients with capillary leak syndrome than in those without: albumin (19% +/- 1.5% vs 30% +/- 6% of the prebypass value, p < 0.05), immunoglobulin G (17% +/- 1.5% vs 29% +/- 5.5%, p < 0.001), and alpha 2-macroglobulin (15% +/- 1.2% vs 25% +/- 4%, p < 0.02). During cardiopulmonary bypass, albumin concentrations remained significantly lower in patients with capillary leak syndrome than in those without, whereas hematocrit values were similar in both groups. During cardiopulmonary bypass, patients with capillary leak syndrome also had lower concentrations of complement proteins C3 and C4 but not C1 inhibitor. C3d/C3 ratio and C5a levels were similar in both patient groups. In contrast, histamine liberation during cardiopulmonary bypass was significantly more pronounced in patients with capillary leak syndrome than in those without (725.2 +/- 396.7 pg/ml vs -54.1 +/- 58.4 pg/ml, p < 0.05). Tumor necrosis factor-alpha levels after protamine administration were also significantly higher in patients with capillary leak syndrome (38.1 +/- 10.0 pg/ml vs 15.3 +/- 3.4 pg/ml, p < 0.05). Leukocyte count during and after cardiopulmonary bypass was similar in both patient groups. This study demonstrates increased protein leakage as early as 10 minutes after initiation of.

Persisting unilateral lung hypoperfusion after resection of a subcarinal bronchogenic cyst

As a rare malformation with a wide variety of clinical modes of presentation, the bronchogenic cyst remains a diagnostic challenge. We report a case with a subcarinal bronchogenic cyst and stenosis of the left main bronchus presenting as "unilateral hyperlucent lung". Hypoplasia of the ipsilateral pulmonary vascular system persisted after surgical restitution of ventilation and is most likely due to an associated vascular malformation. Alternatively, anatomical fixation of pulmonary reflex vasoconstriction can be discussed.

[Extensive acute pulmonary embolism: fragmentation treatment with a rotatable pigtail catheter]

A 58-year-old patient with extensive pulmonary embolism complicated by cardiogenic shock and contraindications to thrombolysis was treated by mechanical embolus fragmentation using a rotatable pigtail catheter system. Considerable recanalization of the left pulmonary arteries was rapidly achieved with relative ease of instrumentation. Subsequently, the hemodynamic condition stabilized.

Chronic venous occlusions in haemodialysis shunts: efficacy of percutaneous treatment

PURPOSE

The efficacy of percutaneous treatment of chronic venous occlusions in haemodialysis fistulae was retrospectively analysed.

MATERIALS AND METHOD

In 33 cases, percutaneous treatment of chronic venous occlusions was attempted. The type of shunt was an autologous arteriovenous fistula in 23 cases and a PTFE implant graft in 10 cases. The lesion involved forearm veins in six cases, an upper arm vein in 15 cases, and a central vein in 12 cases. The mean length of the occlusion was 7.4 +/- 5 cm with a range from 2 to 25 cm. Fresh thrombus material in addition to the chronic occlusion was present in five cases. The patients were referred for chronic shunt dysfunction in 29 cases and with acute shunt thrombosis with an underlying chronic venous occlusion in four cases.

RESULTS

Mechanical recanalization succeeded in 27 of 33 occlusions (82%). In one further patient, direct recanalization failed but an alternative improved drainage was created by detouring the main venous outflow tract by the use of a stent. Immediate clinical success was therefore 85%. Simple balloon dilatation was used in 11 of 27 cases (41%). Additional stent implantation became necessary in 16 of 27 cases (59%). In 15 patients an event of reobstruction occurred during follow-up. Mean primary cumulative patency was 85% after treatment, 41% after 6 months, and 24% after 2 years. By use of reintervention shunt function was maintained at 74% up to 2 years.

CONCLUSIONS

Percutaneous treatment of chronic venous occlusions is technically feasible with a success similar to treatment of stenotic lesions. Follow-up results do not show impaired follow-up data for that type of obstruction.

[Efficiency and efficacy of radiologic diagnosis in skeletal trauma in childhood and adolescence]

In a retrospective analysis, 2,006 X-ray examinations of the skeleton obtained after trauma in 1,386 children were examined; 354 fractures were diagnosed. X-ray films of the skull were requested in 596 (29.7%); fractures were diagnosed in only 13 patients (2.2%). The radiological result changed the medical management in none of these cases. On the other hand, X-ray after trauma in the extremities is indispensable, except for the knee region. Examinations of the lower arm showed a fracture in 54.9%, X-ray of the shoulder 47.7%.

[Diagnostic imaging in the traumatized child]

The value of different radiological procedures in the acute care of injured children is described. Newly developed techniques, e.g., digital luminescent radiography, are discussed. The indications for modern scanning procedures in traumatology and their influence on the examination strategy are shown. The handy use of ultrasound in abdominal injuries is essential if a laparotomy is necessary. Additionally, CT is useful in equivocal cases. Conversely, angiography and MRT are less useful in an emergency situation because of the longer duration of these procedures. Special problems of medical-legal reports are demonstrated. Injuries in the infant and adolescent skeletal system can result in growth delay. In contrast to adults, the growing skeletal system of children has the ability to correct deformations in time.

[A new concept for rational emergency diagnosis of polytrauma patients]

To optimize the emergency care of patients with multiple injuries, a special emergency room with integrated radiological equipment has been developed. It consists of a linear array of a computed tomography system, a mobile C-arm with an integrated scattered radiation grid for conventional films and a C-arm fluorographic system. The intent is to avoid delay caused by transport and repositioning of the patient. It enables all necessary diagnostic procedures to be performed within a minimal amount of time. If there are no emergency patients, the room can be divided by a sliding door and the equipment can be used separately.

Venous stenosis and occlusion in hemodialysis shunts: follow-up results of stent placement in 65 patients

PURPOSE

To provide follow-up data on the use of self-expanding stents in hemodialysis fistulas to improve the technical success of balloon angioplasty.

MATERIALS AND METHODS

Ninety-two self-expanding vascular stents were placed in 65 patients (29 men and 36 women 25-79 years of age; mean, 57.6 years) with failing hemodialysis fistulas or shunts.

RESULTS

Stent placement was successful in all patients, but rethrombosis of the shunt occurred in six patients (10%) within 1 week. There were 96 episodes of reobstruction. In 87 cases, percutaneous or combined surgical and percutaneous repeat intervention was performed. The cumulative shunt function rate was 88% after 6 months, 86% after 1 year, and 77% after 2 years.

CONCLUSION

Stent placement in hemodialysis fistulas helps treat lesions that cannot be adequately treated with percutaneous transluminal angioplasty (PTA) alone but has a follow-up patency rate similar to that of PTA. Standard central venous stents have a better patency rate than after PTA.

[Ultrasound screening of vesico-uretero-renal reflux]

A prospective study of detecting vesicoureteric reflux (VUR) by ultrasound is to be presented. In case of reflux, gas bubbles can be seen in the renal pelvis during the filling phase of a gas cystogram and during micturition, utilizing ultrasound as the imaging modality. In children under two years 52 sonographic reflux studies were performed and compared with radiographic voiding cystourethrograms (VCUG). All higher grade VUR (grades II-IV) have been detected by our method.

[Percutaneous sclerotherapy of varicocele--results in children and adolescents]

65 percutaneous transvenous sclerotherapy of the internal spermatic vein in 58 children and adolescents with varicoceles are reported. Their age ranged from 9.4 to 18 years (mean 14.7 years). The success rate of the sclerotherapy amounted 91.4% while 8.6% recidivations were seen. In three patients slight complications occurred (2 extravasations, 1 spasm of the spermatic vein) which required no further therapy. By repeating the sclerotherapy finally 94.8% of the patients were treated successfully.

CO2 spray mini-injector for digital subtraction angiography versus PC-controlled injection system: experiments in dogs

A personal computer (PC)-controlled CO2 injector (consisting of a pneumatic unit, electric/electronic system, and calculator) and a spray mini-injector (consisting of a CO2 spray can and a dosage chamber) were used in 10 dogs to determine their efficacy regarding imaging quality and ease of handling. CO2 was injected into the abdominal aorta, renal artery, and femoral artery. The vessel diameter was determined on each CO2 arteriogram and compared with that determined on a reference arteriogram obtained using an iodinated contrast agent. The filling ratio (CO2/iodine) was calculated for each set of injection parameters. Both injection systems provided good visualization (filling ratio > 0.9) of large and small arteries within a range of injection parameters. In terms of practicality, the spray mini-injector is more appealing, because it is easier to handle and does not require any preparation.