Patent ductus venosus associated with a hyperintense globus pallidum on T1-weighted magnetic resonance imaging and pulmonary hypertension

Presentation of Congenital Portosystemic Shunts in Children

Background: Congenital portosystemic shunts (CPSS) are rare vascular anomalies resulting in communications between the portal venous system and the systemic venous circulation, affecting an estimated 30,000 to 50,000 live births. CPSS can present at any age as a multi-system disease of variable severity mimicking both common and rare pediatric conditions. Case presentations: Case A: A vascular malformation was identified in the liver of a 10-year-old girl with tall stature, advanced somatic maturation, insulin resistance with hyperinsulinemia, hyperandrogenemia and transient hematuria. Work-up also suggested elevated pulmonary pressures. Case B: A young girl with trisomy 8 mosaicism with a history of neonatal hypoglycemia, transient neonatal cholestasis and tall stature presented newly increased aminotransferase levels at 6 years of age. Case C: A 3-year-old boy with speech delay, tall stature and abdominal pain underwent abdominal ultrasound (US) showing multiple liver nodules, diagnosed as liver hemangiomas by hepatic magnetic resonance imaging (MRI). Management and outcome: After identification of a venous malformation on liver Doppler US, all three patients were referred to a specialized liver center for further work-up within 12 to 18 months from diagnosis. Angio-computed tomography (CT) scan confirmed the presence of either an intrahepatic or extrahepatic CPSS with multiples liver nodules. All three had a hyperintense signal in the globus pallidus on T1 weighted cerebral MRI. Right heart catheterization confirmed pulmonary hypertension in cases A and C. Shunts were closed either using an endovascular or surgical approach. Liver nodules were either surgically removed if there was a risk of malignant degeneration or closely monitored by serial imaging when benign. Conclusion: These cases illustrate most of the common chief complaints and manifestations of CPSS. Liver Doppler US is the key to diagnosis. Considering portosystemic shunts in the diagnostic work-up of a patient with unexplained endocrine, liver, gastro-intestinal, cardiovascular, hematological, renal or neurocognitive disorder is important as prompt referral to a specialized center may significantly impact patient outcome.

Catheter interventional treatment of congenital portosystemic venous shunts in childhood

OBJECTIVES

The study aimed on the catheter interventional treatment of congenital portosystemic venous shunt (CPSVS) in childhood and the impact on vascular growth of hypoplastic portal veins. Clinical course and follow up of partial or complete closure of CPSVS are described.

BACKGROUND

CPSVS is a very rare vascular malformation of the portal venous drainage resulting in potentially life threatening abdominal, pulmonary, cerebral, and cardiac complications. The anatomic type, clinical course, and diagnosis must be determined for optimal management.

METHODS

Single centre case series.

RESULTS

Eight (6 female) children with extrahepatic (n = 5) and intrahepatic (n = 3) CPSVS were diagnosed invasively by catheterization, including test balloon occlusion of the shunt and simultaneous retrograde angiography, and treated by catheter interventions (n = 5) with partial (n = 2) and complete (n = 3) occlusion of CPSVS at a median age of 3.9 years (range 0.7-21). Congenital heart disease (CHD) was the most frequent associated organ manifestation (n = 5) followed by mild to severe pulmonary arterial hypertension (n = 4), hepatopulmonary syndrome (n = 2), and portosystemic encephalopathy (n = 1). CHD was simple (n = 3) or complex type (n = 2). Three patients were untreated so far, because they were in excellent clinical condition at an age <1 year, refused treatment, or planned for later treatment.

CONCLUSIONS

Accurate invasive diagnosis of CPSVS with test balloon occlusion of the shunt is mandatory to depict the anatomic situation. Catheter interventional treatment of CPSVS offers a feasible and safe approach with complete or partial closure of the vascular malformation inducing potentially significant vascular growth of a former hypoplastic portal venous system. © 2015 Wiley Periodicals, Inc.

Complications of congenital portosystemic shunts in children: therapeutic options and outcomes

BACKGROUND AND OBJECTIVE

Congenital portosystemic shunts are rare vascular malformations that lead to severe complications. Their management is controversial. The aim of this study was to propose a clear definition of the risks and management of congenital portosystemic shunts in children according to our experience and a review of the literature.

PATIENTS AND METHODS

Twenty-two children with a complicated congenital portosystemic shunt were studied in our institution. When necessary, management included portal pressure measurement and portal vein angiography during an occlusion test and closure of the shunt by surgical and/or endovascular methods.

RESULTS

Five neonates with intrahepatic shunts presented with cholestasis that resolved spontaneously, and 17 older children presented with liver tumors (13) and/or hepatopulmonary syndrome (2), pulmonary artery hypertension (3), portosystemic encephalopathy (3), heart failure (1), and glomerulonephritis (1). The portosystemic shunt was extrahepatic (11) or intrahepatic (6). Portosystemic shunts were closed by endovascular methods in 5 children and surgically in 10, 4 of whom had portal pressure during occlusion above 35 mmHg and extremely hypoplastic or undetectable portal veins requiring banding of the fistula before closure. Shunt closure resulted in restoration of intrahepatic portal flow in all, with complete or partial regression of benign liver masses, and regression or stabilization of pulmonary, cardiac, neurological, and renal complications.

CONCLUSIONS

Congenital portosystemic shunt carries risks of severe complications in children. Closure of a shunt persisting after age 2 years should be considered preventively. Intrahepatic portal flux restoration can be expected, even when intrahepatic portal veins are extremely hypoplastic or undetectable.

Remittent hyperammonemia in congenital portosystemic shunt

Congenital portosystemic shunts (PSS) are rare vascular anomalies with different gross anatomy. Persistent patent ductus venosus (PDV) represents an uncommon cause of intrahepatic PSS. The diagnosis of this condition may not be obvious because of its wide spectrum of clinical manifestations, ranging from asymptomatic to life-threatening disease. We report the case of three boys with neuropsychological symptoms associated with mild fasting hyperammonemia. An oral protein load allowed the detection of a detoxication defect due to PSS related to PDV. This simple procedure can be worthwhile of attention in patients with mental retardation, behavior disturbances, and learning difficulties after exclusion of common causes of inherited hyperammonemia, namely, urea cycle disorders, organic acidemias, and fatty acid oxidation defects.

Magnetic resonance imaging of brain in patients with cirrhotic and non-cirrhotic portal hypertension

BACKGROUND

Hyperintense signals in the basal ganglia, namely the globus pallidus, have been reported on magnetic resonance imaging (MRI) in 70-100% of patients with cirrhosis of the liver. Deposition of paramagnetic substances, particularly manganese (Mn), has been reported to be responsible for these hyperintense signals. They are found in cirrhotics with or without overt/subclinical hepatic encephalopathy. Deposition of Mn has been attributed to hepatocellular failure and/or portosystemic shunting. Reports of MRI brain findings in patients with extra hepatic portal venous obstruction (EHPVO) and non-cirrhotic portal fibrosis (NCPF) are scanty in the literature.

AIMS

The purpose was to determine the basal ganglia changes on MRI in patients with EHPVO and NCPF and to compare it with patients with cirrhosis of the liver.

PATIENTS AND METHODS

A total of 27 patients (EHPVO = 10, mean age 28.4 +/- 19.0 years, NCPF = 7, mean age 37.1 +/- 10.4 years, cirrhosis = 10, mean age 47.0 +/- 19.6 years) was studied prospectively from January to December 2001. MRI of the brain was done with a standard spin echo axial T1- and fast spin echo T2-weighted scan obtained on a 1.5-T MRI unit. Two radiologists in a blinded fashion graded the signal intensity of basal ganglia on T1-weighted (T1 W) sequences by comparing it with the adjacent unaffected grey matter.

RESULTS

None of the patients with EHPVO or NCPF had any past history of hepatic decompensation and/or overt encephalopathy. Seven (70%) of the cirrhotics had a past history of overt encephalopathy. None of the patients with EHPVO showed any hyperintensity of basal ganglia on T1-weighted MRI images. Hyperintense globus pallidus was seen in four (57%) and eight (80%) patients with NCPF and cirrhosis, respectively.

CONCLUSION

Hyperintense globus pallidus on MRI is common in patients liver cirrhosis and also occurs in patients with NCPF. Patients with EHPVO do not have hyperintense globus pallidus on T1-weighted MRI images.

Pulmonary hypertension in patients with congenital portosystemic venous shunt: a previously unrecognized association

BACKGROUND

Pulmonary arterial hypertension has been reported to be observed in association with acquired portal hypertension. However, the contribution of congenital anomalies occurring in the portal system to the development of pulmonary arterial hypertension remains to be elucidated.

METHODS

Nine patients with congenital portosystemic venous shunt were studied from January 1990 through September 2005.

RESULTS

Patent ductus venosus was detected in 5 patients, including 3 patients with an absence of the portal vein. The presence of either a gastrorenal or splenorenal shunt was evident in another 4 patients. Six patients had a history of hypergalactosemia with normal enzyme activities, as seen during neonatal screening. Six (66.7%) of the 9 patients were identified to have clinically significant pulmonary arterial hypertension (mean pulmonary artery pressure: 34-79 mm Hg; pulmonary vascular resistances: 5.12-38.07 U). The median age at the onset of pulmonary arterial hypertension was 12 years and 3 months. Histologic studies of lung specimens, which were available in 4 of the 9 patients with congenital portosystemic venous shunt, showed small arterial microthrombotic lesions in 3 patients. This characteristic finding was recognized even in the congenital portosystemic venous shunt patients without PAH.

CONCLUSIONS

This study demonstrated thromboembolic pulmonary arterial hypertension to be a crucial complication in congenital portosystemic venous shunt, and this pathologic state may be latently present in patients with pulmonary arterial hypertension of unknown etiology.

High pallidal T1 signal is rarely observed in obstructive jaundice, but is frequently observed in liver cirrhosis

Although high signal intensities in the globus pallidus are frequently observed in T1-weighted magnetic resonance images (MRI) of patients with liver cirrhosis, it is unclear whether these increases are due to portal-systemic shunt or obstruction of biliary excretion. We therefore studied pallidal signals in 18 cancer patients with bile duct obstruction and marked jaundice (>10 mg/dl). Patients who had fever, leukocytosis or liver cirrhosis were excluded to ensure that jaundice was due to bile duct obstruction. All patients showed a dilated intrahepatic duct on computed tomography (CT) scan. A high pallidal signal was observed in one of 18 biliary obstructive patients whereas high signals were highly prevalent in liver cirrhosis. A portal-systemic shunt rather than an obstruction of biliary excretion may be responsible for the increased blood manganese concentrations and pallidal T1 signals in chronic liver diseases.

Manganese accumulation in the brain: MR imaging

Manganese (Mn) accumulation in the brain is detected as symmetrical high signal intensity in the globus pallidi on T1-weighted MR images without an abnormal signal on T2-weighted images. In this review, we present several cases of Mn accumulation in the brain due to acquired or congenital diseases of the abdomen including hepatic cirrhosis with a portosystemic shunt, congenital biliary atresia, primary biliary cirrhosis, congenital intrahepatic portosystemic shunt without liver dysfunction, Rendu-Osler-Weber syndrome with a diffuse intrahepatic portosystemic shunt, and patent ductus venosus. Other causes of Mn accumulation in the brain are Mn overload from total parenteral nutrition and welding-related Mn intoxication.

Spontaneous occlusion of brainstem arteriovenous malformation following ligature of a hepatic patent ductus venosus. Case report and review of the literature

The authors describe the clinical and radiological findings in a case of brainstem arteriovenous malformation (AVM) associated with a hepatic patent ductus venosus (PDV) in a 12-year-old child. The AVM was discovered on magnetic resonance (MR) imaging performed because of slight mental retardation and headache. The malformation was otherwise asymptomatic and no treatment was proposed. An abdominal ultrasonography study performed 1 year later because of hyperammonemia revealed a PDV, which was surgically ligated. One year later, MR images and angiograms showed complete resolution of the brainstem AVM. This report is the first documentation of an association between these two entities in the same patient, and the possible pathophysiological interactions between them are discussed.

Anastomoses portosystémiques intrahépatiques idiopathiques : à propos de 4 observations

Intrahepatic portosystemic anastomoses are macroscopic communications between the venous portal system and the systemic circulation and located partly in the liver. We report 4 new cases of type II shunts, which illustrate the circumstances of the diagnosis of these exceptional anomalies. For 2 children, the diagnosis was done antenataly by US and spontaneous involution in a few months was observed. In the third case the malformation was evidenced fortuitously at 3 weeks of life, and this 6-year-old child remains completely asymptomatic so far. Then, in the fourth case, a cerebral venous thrombosis was fortuitously and antenatally evidenced in an otherwise uneventful pregnancy and portosystemic shunt was demonstrated postnataly in the extensive work up of the neonate.

Patent ductus venosus in children: a case report and review of the literature

A 10-year-old girl with a patent ductus venosus associated with multiple autoimmune disorders presented with hypoxia, cyanosis of her lips, and exertional dyspnea. Ultrasonography and abdominal computed tomography of the liver showed a communication between the portal vein and the inferior vena cava through a patent ductus venosus. Portography showed flow from the portal vein directly into the inferior vena cava via the portosystemic shunt. The portosystemic venous shunt ratio was estimated to be 71.8% by scintigraphy using 123I-IMP. Intraoperatively, the authors diagnosed this portosystemic shunt as patent ductus venosus because of the absence of the ductus venosus on real anatomic position. The portal venous pressure was 8.2 cm H2O, which increased to 17.7 cm H2O when the ductus venosus was temporarily occluded. After surgical ligation of the ductus venosus, the color of liver improved, indicating restored liver circulation. The postoperative course was uneventful, and the patient has been asymptomatic for 6 months.

Patent ductus venosus with a hypoplastic intrahepatic portal system presenting intrapulmonary shunt: a case treated with banding of the ductus venosus

A case of patent ductus venosus (PDV) presenting intrapulmonary shunting is described. Although retrograde venography of ductus venosus showed few intrahepatic branches, banding of PDV resulted in increased intrahepatic portal branches and disappearance of symptoms 10 months after the operation. Banding of the ductus venosus may be effective in PDV even with hypoplastic intrahepatic portal system.

Manganese deposits in patients with biliary atresia after hepatic porto-enterostomy

PURPOSE

The aim of this study was to determine if there is latent manganese toxicity in patients with biliary atresia.

METHODS

Fifteen children with biliary atresia were examined postoperatively with regard to whole-blood manganese levels using brain magnetic resonance imaging (MRI) and I-123 iodoamphetamine (IMP) per rectal portal scintigraphy.

RESULTS

Nine (60%) of the 15 had high whole-blood manganese levels (mean, 4.1 microg/dL; range, 1.2 to 9.6; normal, 0.5 to 2.5), and these 9 had hyperintense globus pallidus on T1-weighted images, with no corresponding signal change in T2 sequences. I-123 IMP per rectal portal scintigraphy was done for 13 patients to evaluate portosystemic shunt flow. 12 (92%) of these patients had an increased flow. Mean shunt ratio was estimated to be 41% (range, 0.6 to 98; normal, <5%). Encephalopathy was evident in only 1 patient.

CONCLUSIONS

Some patients with biliary atresia in the postoperative period have manganese deposits in globus pallidus on T1-weighted images and high whole-blood manganese levels, possibly caused by increased portsystemic shunt, and a latent or subclinical encephalopathy is also present.

Manganese deposition in basal ganglia structures results from both portal-systemic shunting and liver dysfunction

BACKGROUND & AIMS

Manganese (Mn) deposition could be responsible for the T(1)-weighted magnetic resonance signal hyperintensities observed in cirrhotic patients. These experiments were designed to assess the regional specificity of the Mn increases as well as their relationship to portal-systemic shunting or hepatobiliary dysfunction.

METHODS

Mn concentrations were measured in (1) brain samples from basal ganglia structures (pallidum, putamen, caudate nucleus) and cerebral cortical structures (frontal, occipital cortex) obtained at autopsy from 12 cirrhotic patients who died in hepatic coma and from 12 matched controls; and from (2) brain samples (caudate/putamen, globus pallidus, frontal cortex) from groups (n = 8) of rats either with end-to-side portacaval anastomosis, with biliary cirrhosis, or with fulminant hepatic failure as well as from sham-operated and normal rats.

RESULTS

Mn content was significantly increased in frontal cortex (by 38%), occipital cortex (by 55%), pallidum (by 186%), putamen (by 66%), and caudate (by 54%) of cirrhotic patients compared with controls. Brain Mn content did not correlate with patient age, etiology of cirrhosis, or history of chronic hepatic encephalopathy. In cirrhotic and portacaval-shunted rats, Mn content was increased in pallidum (by 27% and 57%, respectively) and in caudate/putamen (by 57% and 67%, respectively) compared with control groups. Mn concentration in pallidum was significantly higher in portacaval-shunted rats than in cirrhotic rats. No significant changes in brain Mn concentrations were observed in rats with acute liver failure.

CONCLUSIONS

These findings suggest that brain Mn deposition results both from portal-systemic shunting and from liver dysfunction.

The long-term prognosis of congenital portosystemic venous shunt

Congenital portosystemic venous shunt (PSVS), considered to be a rare disease, can lead to hepatic encephalopathy (HE). With improvements in diagnostic imaging techniques, the number of infants and children with documented PSVS has increased. The natural course of the disease and indications for surgical closure of the shunt vessel have not been well defined. We reviewed 51 cases of congenital PSVS in Japan; 34 patients had an intrahepatic PSVS, and 17 had an extrahepatic PSVS. There were 12 patients with HE at the time of diagnosis. The frequency of HE increased in subjects over 60 years of age. Children with HE had a shunt ratio exceeding 60%. When the shunt ratio was less than 30%, HE did not occur. Twenty of 28 patients under the age of 15 years had hypergalactosemia at the time of neonatal screening. Part of the congenital intrahepatic PSVS spontaneously closed. Surgical closure of a PSVS may be an approach expected to prevent HE when the shunt ratio exceeds 60%.

Patent ductus venosus

BACKGROUND

Patent ductus venosus is extremely rare with only 14 cases reported in the world literature. We present a case of patent ductus venosus.

METHODS AND RESULTS

A 29-year-old male was admitted with melaena stool caused by gastric haemorrhagic ulcers. Laboratory data disclosed severe anaemia; however, liver function tests were normal. Serum ammonia was also within the normal range. Serological viral markers for hepatitis B or C were all negative. The abdominal ultrasonography and computed tomography indicated a 12 mm diameter shunt located in the left lobe of the liver, which connected the portal vein with the left hepatic vein. After treatment for gastric ulcers, percutaneous transhepatic portography was performed and an enormous shunt connecting the umbilical portion of the portal vein with the left hepatic vein was revealed.

CONCLUSIONS

Histological findings of the liver biopsy showed that portal venules could not be observed in the portal areas and that no fibrosis or inflammatory cell infiltration were shown. Because of the anatomical position of the shunt, the case was diagnosed as patent ductus venosus.

Role of manganese in the pathogenesis of portal-systemic encephalopathy

Amongst the potential neurotoxins implicated in the pathogenesis of hepatic encephalopathy, manganese emerges as a new candidate. In patients with chronic liver diseases, manganese accumulates in blood and brain leading to pallidal signal hyperintensity on T1-weighted Magnetic Resonance (MR) Imaging. Direct measurements in globus pallidus obtained at autopsy from cirrhotic patients who died in hepatic coma reveal 2 to 7-fold increases of manganese concentration. The intensity of pallidal MR images correlates with blood manganese and with the presence of extrapyramidal symptoms occurring in a majority of cirrhotic patients. Liver transplantation results in normalization of pallidal MR signals and disappearance of extrapyramidal symptoms whereas transjugular intrahepatic portosystemic shunting induces an increase in pallidal hyperintensity with a concomitant deterioration of neurological dysfunction. These findings suggest that the toxic effects of manganese contribute to extrapyramidal symptoms in patients with chronic liver disease. The mechanisms of manganese neurotoxicity are still speculative, but there is evidence to suggest that manganese deposition in the pallidum may lead to dopaminergic dysfunction. Future studies should be aimed at evaluating the effects of manganese chelation and/or of treatment of the dopaminergic deficit on neurological symptomatology in these patients.