Role of embolisation in the treatment of bronchopulmonary sequestration

BACKGROUND

Sequestrations represent bronchopulmonary malformations that are increasingly diagnosed antenatally. After birth, the therapeutic approach in asymptomatic children is debated, as some may spontaneously regress.

OBJECTIVE

To evaluate the efficacy of embolisation of the feeding systemic artery in the treatment of bronchopulmonary sequestration.

MATERIALS AND METHODS

Sixteen children with bronchopulmonary sequestration were treated by endovascular embolisation of the feeding systemic artery.

RESULTS

Ten patients were considered cured by embolisation alone. One patient was operated on after unsuccessful embolisation, three had partial regression of the lung mass and two are still under follow-up.

CONCLUSIONS

Our experience indicates that bronchopulmonary sequestrations in children can be treated by embolisation alone.

Intracranial venous anomalies associated with atretic cephalocoeles

BACKGROUND

Midline scalp lesions are frequent in children. They include soft-tissue masses and atretic meningocoeles. Their recognition is important as their treatment differs. Intracranial venous anomalies are known to be associated with atretic cephalocoeles.

MATERIALS AND METHODS

A retrospective study was undertaken to assess the frequency of intracranial venous anomalies associated with atretic meningocoeles (AT). Thirty-one patients with AT were studied by MRI. There were 13 meningocoeles and 14 encephalocoeles; 4 have not yet received surgery.

RESULTS

Venous anomalies were found when the cephalocoeles lay above the torcular. They include absence of the straight sinus and duplication of the longitudinal sinus.

CONCLUSION

Venous anomalies are frequent in atretic cephalocoeles and are part of the dysraphic state.

Noninvasive diagnosis of brain tumours in children

The author reviews the progress made during the last 25 years in noninvasive diagnosis of brain tumours in children. MRI has replaced all other modalities available at that time. The diagnosis is still based on a precise anatomical analysis of the lesion rather than on other specific findings. New techniques, such as spectroscopy and diffusion, may help to characterise further brain tumours in children preoperatively.

Emergency management of deeply comatose children with acute rupture of cerebral arteriovenous malformations

PURPOSE

To assess the impact of emergency management on mortality and morbidity of acute rupture of cerebral arteriovenous malformations resulting in deep coma in children, and the factors predicting outcome.

METHODS

Retrospective chart review of 20 children with a Glasgow Coma Scale < or = 8 with acute hemorrhagic stroke from a cerebral arteriovenous malformation rupture was conducted. Protocol included: early resuscitation with tracheal intubation and ventilation after induction of anesthesia with sufentanil, and benzodiazepine, and mannitol 20% or hypertonic saline 7.5% infusion for life-threatening brain herniation. Radiological exploration was limited to contrast-enhanced CT scan preceding immediate surgical decompression. Postoperatively, children were deeply sedated and intracranial pressure monitoring allowed titration with osmotherapy, vasopressors, hyperventilation or barbiturate coma to control cerebral perfusion pressure. Analysis used stratification of the type of hemorrhage (supra or infra tentorial), location (intraparenchymal and subarachnoid, intraparenchymal and intraventricular or intraventricular alone) and relationship between presentation, evolution with resuscitation, type of cerebral lesion, and outcome.

RESULTS

Patients had a severe initial presentation (median Glasgow Coma Scale five), eight had unilateral and eight bilateral third nerve palsy. Compressive hematoma in supratentorial localisation represented 75% of the cases. Global mortality was 40%. Persistence of mydriasis after resuscitation increased mortality to 75%. Massive intraventricular flooding was associated with increased mortality. Good functional outcome was achieved in survivors.

CONCLUSION

Acute rupture of an AVM can result in rapidly progressing coma. Emergency management with early resuscitation, minimal radiological exploration before rapid surgical decompression results in a mortality rate of 40%, but a good functional outcome can be expected in the survivors.

[Brain functional MRI: physiological, technical, and methodological bases, and clinical applications]

Brain functional MRI (fMRI) provides an indirect mapping of cerebral activity, based on the detection of the local blood flow and oxygenation changes following neuronal activity (BOLD contrast, Blood Oxygenation Level Dependent). fMRI allows us to study non invasively the normal and pathological aspects of cortical functional organization. Each fMRI study compares two different states of activity. Echo-Planar Imaging (EPI) is the technic of choice that makes it possible to study the whole brain at a rapid pace. Activation maps are calculated from a statistical analysis of the local signal changes. Functional MRI is now becoming an essential tool in the neurofunctional work-up of many neurosurgery patients, as well as the reference method to image normal or pathologic functional brain organization in adults and children.

[Radiologic approach to community-acquired pneumonia]

X-ray investigation is of real use in the therapeutic decision in cases of acute lower respiratory tract infections in children. Systematic lateral chest radiography must be abandoned. Follow up chest radiography may be performed 2 weeks after initiating the treatment. Chest scan is only useful in a limited number of selected indications.

[Ulnar dimelia: imaging modalities and surgical implications]

PURPOSE

To report 2patients with ulnar dimelia.

METHODS

Plain radiographs (2patients), angiography (1patient), MR (2patients), CT (2patients) with 3Dreconstruction (1patient) were performed.

RESULTS

Unilateral polydactyly with absence of the thumb, ulnar duplication with absence of radius were observed in both patients. Shoulder dislocation was present in one patient. Vascular anomalities were observed in one patient who underwent angiography but did not interfere with polydactyly surgical treatment and pollicisation. CT with 3D helped in delineating the elbow and shoulder bone abnormalities and thus in planning elbow osteotomies. MR was helpful in imaging muscle anatomy.

CONCLUSIONS

Ulnar dimelia or "mirror hand" is a rare congenital disorder of the upper limb. Approximately 70cases have been reported, including 3 with shoulder dislocation. A multimodality imaging approach, exploring the various aspects of the malformation is mandatory to help the surgeon in order to obtain a functional and aesthetic upper limb after complex surgical procedures taking into account the various aspects of the malformation.

Practical management of hyperinsulinism in infancy

Hyperinsulinism in infancy is one of the most difficult problems to manage in contemporary paediatric endocrinology. Although the diagnosis can usually be achieved without difficulty, it presents the paediatrician with formidable day to day management problems. Despite recent advances in understanding the pathophysiology of hyperinsulinism, the neurological outcome remains poor, and there is often a choice of unsatisfactory treatments, with life long sequelae for the child and his or her family. This paper presents a state of the art overview on management derived from a consensus workshop held by the European network for research into hyperinsulinism (ENRHI). The consensus is presented as an educational aid for paediatricians and children's nurses. It offers a practical guide to management based on the most up to date knowledge. It presents a proposed management cascade and focuses on the clinical recognition of the disease, the immediate steps that should be taken to stabilise the infant during diagnostic investigations, and the principles of definitive treatment.

Cerebral white matter disease in children may be caused by mitochondrial respiratory chain deficiency

Several mitochondrial diseases are known to occasionally involve the cerebral white matter, namely Leigh syndrome, Kearns-Sayre syndrome, and MELAS syndrome, but in these cases the major finding is alteration in the basal ganglia and brainstem. Here we report on severe diffuse white matter involvement and respiratory chain enzyme deficiency or mitochondrial DNA rearrangement in 5 unrelated families. It is interesting that white matter lesions were the only abnormal neuroradiologic feature in 3 of the 5 families, and multiple small cyst-like white matter lesions were found in 2 of 5 probands. Respiratory chain deficiency should be considered in the diagnosis of severe white matter involvement in childhood.

Bronchial casts in children with cardiopathies: the role of pulmonary lymphatic abnormalities

Expectoration of bronchial casts, a condition also called plastic bronchitis, is very rare in children. Bronchial casts may be associated with bronchopulmonary diseases associated with mucus hypersecretion, bronchopulmonary bacterial infections, congenital and acquired cardiopathies, or pulmonary lymphatic abnormalities. A classification based on anatomy and pathology has been proposed which identifies an "acellular" group associated with congenital cardiopathies and palliative surgery. We report on 3 cases with bronchial casts associated with cardiopathy. Observations suggest that the formation of bronchial casts may result from lymphatic leakage into the bronchi. The 3 cases on which we report were immunodeficient and had pulmonary lymphatic abnormalities. The bronchial casts contained lymphocytes and lipids, as determined by histologic examination. In the absence of congenital pulmonary or diffuse lymphatic dysplasia associated with cardiopathy, the principal factors resulting in the formation of bronchial casts appear to be surgical trauma to the lymphatic channels surrounding the bronchi, pleural adhesions, and high systemic venous blood pressure. The prognosis for these patients is poor, and possibilities for treatment are limited.

Protein hydrolysis by colorado potato beetle, leptinotarsa decemlineata, digestive proteases: the catalytic role of cathepsin D

Although several studies were carried out over the last 15 years to assess the nature and characteristics of digestive proteases in herbivorous insects, little is known about the relative importance of these enzymes in the hydrolysis of specific dietary proteins. In this study, we assessed the involvement of Colorado potato beetle (CPB; Leptinotarsa decemlineata Say, Chrysomelidae) aspartate, cysteine, and serine digestive proteinases in the degradation of two model substrates: ribulose biphosphate carboxylase/oxygenase, the major protein in potato leaves, and the pro-region of papaya proteinase IV, a cysteine protease inhibitor (PI) susceptible to proteolysis by the insect "nontarget" proteases. As shown by the use of various combinations of diagnostic PIs specific to the different classes of CPB proteinases, the insect aspartate (cathepsin D-like) proteinase activity is important in initiating the hydrolysis of both proteins when the insect is feeding on potato, while cysteine (cathepsin B/cathepsin H-like) and serine (chymotrypsin-like) proteinase activities would be involved in subsequent steps of the hydrolytic process. Similar observations were made with diet-induced variants of the insect protease system, suggesting the importance of digestive cathepsin D and the sequential hydrolysis of dietary proteins in CPB, regardless of the diet ingested. Based on these observations, a preliminary model is proposed to explain dietary protein hydrolysis in CPB, also taking into account the information currently available about the distribution of digestive endo- and exopeptidases in the midgut of CPB. The potential of a wound-induced cathepsin D inhibitor from tomato in developing CPB-resistant transgenic potato lines is also discussed, after demonstrating the "pepstatin-like" effect of a recombinant form of this proteinaceous inhibitor against the insect cathepsin D. Arch. Copyright 1999 Wiley-Liss, Inc.

Intussusception in infants and children: feasibility of ambulatory management

To evaluate the ambulatory management of ileo-colic intussusception in infants and children, a retrospective study over 3 years of 113 children treated for ileo-colic intussusception in a paediatric emergency department was undertaken with the aim of shortening the length of stay. A total of 113 children aged 10 days to 9 years (median 12 months) were treated for intussusception between January 1993 and December 1996. None had septic shock or peritoneal aeric effusion. Barium enema reduction was attempted in all patients. Successful reduction rate was 81%. Fifty patients (44.2%) were completely ambulatory managed and 42 were hospital-supervised after successful enema reduction. Twenty-one children underwent laparotomy after failure of enema. With the ambulatory device, costs were reduced ($1000/case) compared with conventional in-patient treatment. Outpatient treatment of acute ileo-colic intussusception is secure and reduces costs. It depends on the willingness of the medical team but requires simultaneous adaptation of hospital funding to promote this trend.

Idiopathic growth hormone deficiency: presentation, diagnostic and treatment during childhood

The clinical and biological presentation of idiopathic growth hormone (GH) deficiency (GHD) varies greatly, demonstrating the variety of its pathogenic features and explaining why it is difficult to diagnose. We examined 48 patients (26 males) with certain idiopathic GHD diagnosed at 4.8 +/- 0.7 yr. The symptoms that led to the diagnosis of GHD were low growth rate (33 cases), hypoglycemia (12 cases), microphallus (1 case) and in 2 cases the GHD was diagnosed from magnetic resonance imaging (MRI) performed for delayed mental development (1 case), or congenital blindness (1 case). The 2 other cases were diagnosed from routine GH evaluation performed at birth because of idiopathic GHD in siblings. Thirteen had congenital malformation. Twenty three cases (48%) had features suggesting that the GHD was of antenatal origin. Six of them were born by breech delivery. Twenty one cases (44%) had features suggesting a hypothalamic origin. The decrease in growth rate occurred before 0.5 year in 21 (55%), before 1 year in 27 (71%) and before 2 years in 30 (79%): 8 patients (21%) maintained a normal growth rate after this age. Among these 8 patients, 5 had signs suggesting an antenatal origin and 4 had severe episodes of hypoglycemia from birth. The mean GH peak after the pharmacological stimulation test was 3.6 +/- 0.5 micrograms/l. The mean plasma insulin-like growth factor 1 (IGFI) was 0.1 +/- 0.02 U/ml. The GH deficiency was associated with deficiencies of thyrotropin in 26 (54%) and of adrenocorticotrophic hormone in 17 (35%) patients. Among the 15 patients of pubertal age, 9 (60%) had gonadotrophin deficiency. No patient had diabetes insipidus. The MRI showed pituitary stalk interruption syndrome in 39 patients and normal pituitary anatomy in 6 patients. GH treatment reduced the difference between target and actual heights from 3.5 SD (before) to I SD (after 3 years) in the 39 more recently seen patients given 0.5-0.6 U/kg/w GH in 6 or 7 weekly injections. Height gain during the first year and cumulative height gain over 3 years (SD) was correlated negatively with height (SD) at the start of treatment (p < 0.01). We conclude that most of the patients with GHD have features suggesting an antenatal origin. Despite this early origin, the decreased growth rate may occur after 2 years.

Juvenile rheumatoid arthritis and lymphoedema: lymphangiographic aspects

We report a 5 1/2-year-old boy with juvenile rheumatoid arthritis (JRA) and lower-limb lymphoedema. US, MRI and lymphangiography were performed. Based on the lymphangiographic study, we propose a pathogenesis based on obstruction of normal superficial lymphatic vessels in the affected limb. This is discussed with other pathogenetic factors proposed in the 16 previously reported cases of lymphoedema complicating JRA.

Surgery of epilepsy associated with focal lesions in childhood

OBJECT

Surgery in children with epilepsy is a new, evolving field. The important practical issues have been to define strategies for choosing the most suitable candidates and the type and optimal timing of epilepsy surgery. This study was undertaken to elucidate these points.

METHODS

To identify the factors that correlated with outcome, the authors analyzed a series of 200 children (aged 1-15 years (mean 8.7 years) who underwent surgery between 1981 and 1996 at the Hôpital Necker-Enfants Malades. In 171 cases (85.5%) the epilepsy was medically refractory and was associated with focal cortical lesions. Surgery consisted of resection of the lesion without specifically attempting to identify and remove the "epileptogenic area. "In the group of children whose seizures were medically refractory, the mean follow-up period was 5.8 years. According to Engel's classification, 71.3% of these children became seizure free (Class 1a,) whereas 82% were in Class I. A multivariate statistical analysis revealed that among all the factors studied, the success of surgery in a patient in whom there was a good clinical/electroencephalogram/imaging correlation depended on the patient's having undergone a minimally traumatic operation, a complete resection of the lesion, and a short preoperative seizure duration. After the surgical control of epilepsy, behavior disorders were more improved (31% of all patients) than cognitive function (25%). The patient age at onset, duration and frequency of seizures, intractability of the disease to therapy, and seizure characteristics were correlated with cognitive, behavioral, and academic performance pre- and postoperatively. Multivariate statistical analysis revealed that cognitive dysfunction correlated highly with the duration of epilepsy prior to surgery, whereas behavioral disorders correlated more with seizure frequency.

CONCLUSIONS

These data must be taken into account when selecting patients for surgical treatment and when deciding the timing of surgery. Early surgical intervention allows for optimum brain development.

Clinical features of 52 neonates with hyperinsulinism

BACKGROUND

Neonatal hyperinsulinemic hypoglycemia is often resistant to medical therapy and is often treated with near-total pancreatectomy. However, the pancreatic lesions may be focal and treatable by partial pancreatic resection.

METHODS

We studied 52 neonates with hyperinsulinism who were treated surgically. The type and location of the pancreatic lesions were determined by preoperative pancreatic catheterization and intraoperative histologic studies. Partial pancreatectomy was performed in infants with focal lesions, and near-total pancreatectomy was performed in those with diffuse lesions. The postoperative outcome was determined by measurements of plasma glucose and glycosylated hemoglobin and by oral glucose-tolerance tests.

RESULTS

Thirty neonates had diffuse beta-cell hyperfunction, and 22 had focal adenomatous islet-cell hyperplasia. Among the latter, the lesions were in the head of the pancreas in nine, the isthmus in three, the body in eight, and the tail in two. The clinical manifestations were similar in both groups. The infants with focal lesions had no symptoms of hypoglycemia and had normal preprandial and postprandial plasma glucose and glycosylated hemoglobin values and normal results on oral glucose-tolerance tests after partial pancreatectomy (performed in 19 of 22 neonates). By contrast, after near-total pancreatectomy, 13 of the patients with diffuse lesions had persistent hypoglycemia, type 1 diabetes mellitus developed in 8, and hyperglycemia developed in another 7; overall, only 2 patients with diffuse lesions had normal plasma glucose concentrations in the first year after surgery.

CONCLUSIONS

Among neonates with hyperinsulinism, about half may have focal islet-cell hyperplasia that can be treated with partial pancreatectomy. These neonates can be identified through pancreatic catheterization and intraoperative histologic studies.

Loss of imprinted genes and paternal SUR1 mutations lead to hyperinsulinism in focal adenomatous hyperplasia

Two types of histopathological lesions, a focal adenomatous hyperplasia of islet cells of the pancreas in about 30% of operated sporadic cases, and a diffuse form can be observed in congenital hyperinsulinism, or Persistent Hyperinsulinemic Hypoglycemia of Infancy (PHHI). In sporadic focal forms, specific losses of maternal alleles (LOH) of the imprinted chromosomal region 11p15, restricted to the hyperplastic area of the pancreas, were observed. Similar mechanisms are observed in embryonal tumors and in the Beckwith-Wiedemann syndrome which is also associated with neonatal but transient hyperinsulinism. However this region also contains the sulfonylurea receptor (SUR1) gene and the inward rectifying potassium channel subunit (KIR6.2) gene, involved in recessive familial forms of PHHI, but not known to be imprinted. We now report somatic reduction to hemizygosity or homozygosity of a paternal SUR1 constitutional heterozygous mutation, in five patients with a focal form of PHHI. Thus this somatic event (LOH) which leads both to b cell proliferation and to hyperinsulinism can be considered as the somatic equivalent, restricted to a microscopic focal lesion, of constitutional uniparental disomy associated with unmasking of a heterozygous parental mutation leading to a somatic recessive disorder.

Malignancies in pediatric patients with ataxia telangiectasia

BACKGROUND

Patients with ataxia telangiectasia (AT), known to have an inherent increased susceptibility to the development of cancer, may present with malignancies that are unusual for the patient's age, are often difficult to diagnose clinically and radiographically and respond poorly to conventional therapy.

MATERIALS AND METHODS

We reviewed the clinical presentation and imaging studies of 12 AT patients who developed malignancies.

RESULTS

Eight of the twelve patients developed non-Hodgkin's lymphoma (CNS, thorax, bone), two developed Hodgkin's disease, and two were diagnosed with gastrointestinal mucinous adenocarcinoma.

CONCLUSION

The lymphomas were commonly extra nodal, and infiltrative rather than mass-like. The recognition of the tumors was often delayed due to confusion with the known infectious complications in AT patients.

Imaging of lung vascularization and perfusion in children

Imaging techniques to evaluate lung perfusion are continuously evolving. Chest film is still the first step. Spiral CT has revolutionized chest imaging in children, MRI is still progressing and thanks to it, multiplanar abilities will probably take a great importance in the future. The accessibility of the machine is still a limiting factor. Angiography is now restricted to interventional procedures.

CT scan patterns of pulmonary alveolar proteinosis in children

BACKGROUND

To study computed tomographic (CT) findings in children with pulmonary alveolar proteinosis (PAP) more extensively.

OBJECTIVE

To describe the CT features at the time of diagnosis and after therapeutic broncho-alveolar lavage (BAL).

MATERIALS AND METHODS

We retrospectively reviewed the CT scans of five children (aged 3 months to 4 years) examined because of incidental bronchitis (n = 1), disease in a sibling (n = 1) and relapsing fever, cough and dyspnoea (n = 3). Each patient had an initial CT scan. Two asymptomatic cases were not treated but were followed up by plain chest films. The other three had BAL and follow-up CT.

RESULTS

Initial CT in all cases showed a diffuse reticulomicronodular pattern associated in three cases with posterior bilateral alveolar infiltrates. CT in the two asymptomatic patients remained unchanged or slightly improved without BAL. After BAL, a variable decrease of lung infiltrates was observed.

CONCLUSIONS

Correlation between the extent of alveolar consolidation and severity of disease was found. Anatomical and pathological considerations allow us to consider that the classical reticulomicronodular pattern is not due to an interstitial infiltration but to alveoli filled with the abnormal material characteristic of PAP.