Evidence of Partial Seniority Conservation in the πg_{9/2} Shell for the N=50 Isotones

The reduced transition probabilities for the 4_{1}^{+}→2_{1}^{+} and 2_{1}^{+}→0_{1}^{+} transitions in ^{92}Mo and ^{94}Ru and for the 4_{1}^{+}→2_{1}^{+} and 6_{1}^{+}→4_{1}^{+} transitions in ^{90}Zr have been determined in this experiment making use of a multinucleon transfer reaction. These results have been interpreted on the basis of realistic shell-model calculations in the f_{5/2}, p_{3/2}, p_{1/2}, and g_{9/2} proton valence space. Only the combination of extensive lifetime information and large scale shell-model calculations allowed the extent of the seniority conservation in the N=50 g_{9/2} orbital to be understood. The conclusion is that seniority is largely conserved in the first πg_{9/2} orbital.

Use of Tissue Plasminogen Activator in Abdominal Abscesses in Children-A Single-Center Randomized Control Trial

PURPOSE

To establish the efficacy of once-per-day intracavitary tissue plasminogen activator (tPA) in the treatment of pediatric intra-abdominal abscesses.

METHODS

A single-center prospective, double-blinded, randomized controlled trial of the use of intracavitary tPA in abdominal abscesses in children. Patients were randomized to either tPA-treatment or saline-treatment groups. Primary outcome was drainage catheter dwell (hours). Secondary outcomes were length of hospital stay, times to discharge, clinical and sonographic resolution, and adverse events (AEs).

RESULTS

Twenty-eight children were randomized to either group (n = 14 each). Demographics between groups were not significantly different (age P = .28; weight P = .40; gender P = .44). There were significantly more abscesses in the tPA-treated group (P = .03). Abscesses were secondary to perforated appendicitis (n = 25) or postappendectomy (n = 3). Thirty-four abscesses were drained, 4 aspirated, 3 neither drained/aspirated. There was no significant difference in number of drains (P = .14), drain size (P = .19), primary outcome (P = .077), or secondary outcomes found. No procedural or intervention drug-related AEs occurred. No patient in the saline-treated group required to be switched/treated with tPA.

CONCLUSION

No significant difference in the length of catheter dwell time, procedure time to discharge, or time to resolution was found. Intracavitary tPA was not associated with morbidity or mortality. The results neither support nor negate routine use of tPA in the drainage of intra-abdominal abscess in children. It is possible that a multicentre study with a larger number of patients may answer this question more definitively.

Klippel-Trenaunay Syndrome

Klippel-Trenaunay syndrome or KTS is a complex vascular syndrome associated with overgrowth occurring as a result of somatic mutations in the PIK3CA gene. Patients are diagnosed on the basis of physical findings, sometimes with supportive imaging, of commonly a segmental anomaly with a cutaneous port-wine stain, lymphatic and venous malformations and overgrowth. The severity of the component vascular malformations and the degree of overgrowth varies from patient to patient which demands care given by a multi-professional team with regular follow-up in a specialist clinic. Some patients may present with acute life-threatening problems, often as a result of veno-thromboembolic events (VTEs) especially following surgical and invasive radiological procedures. Awareness of such problems is vital and prophylactic measures to reduce such risks are paramount. The interventional radiologist is vital to the care team as he/she can undertake procedures including endovascular closure of significant venous anomalies which predispose to such VTEs. Although these procedures can be lengthy and complex, they can now provide a minimally invasive means to reduce the risk from life-threatening and sometimes fatal VTEs. The results however from such interventions will require long-term studies which to date are unavailable.

The use of rapamycin to treat vascular tumours and malformations: A single-centre experience

Objectives

To assess the safety and efficacy of rapamycin in treating children with vascular tumours and malformations.

Study design

We performed a retrospective review at a large tertiary care paediatric centre to assess the efficacy and safety of using rapamycin to treat vascular tumours and malformations. Response to therapy was defined by patient-reported symptom improvement, radiological reduction in size of lesions, and/or improvement of laboratory parameters.

Results

Forty-two patients (7 with vascular tumours and 35 with vascular malformations) have been treated with rapamycin. Despite 33 of 42 patients being diagnosed in the first year of life, the median age of initiating rapamycin was 11 years. Of the 38 children treated for a minimum of 4 months, 29 (76%) exhibited a clinical response. Twenty-one patients had follow-up imaging studies and of these, 16 (76%) had radiographic decrease in lesion size. Median time to demonstration of response was 49 days. All five children with vascular tumours and all three children with vascular malformations under the age of 4 years showed a clinical response. Response rate was lower for children ≥ 4 years of age (0/2, 0% for vascular tumours; 21/28, 75% for vascular malformations). No patient experienced an infection directly related to rapamycin or discontinued rapamycin due to toxicity.

Conclusions

Rapamycin is safe and efficacious in most children with select vascular tumours and malformations. Young children appear to respond better, suggesting that early initiation of rapamycin should be considered.

Abnormal hemostasis in children with vascular anomalies, part I: Thrombocytopenias among different vascular anomalies

Long before the classification of vascular anomalies from the International Society for the Study of Vascular Anomalies (ISSVA) provided a framework to differentiate vascular anomalies, otherwise known as vascular birthmarks, it was recognized that patients with such lesions can present with acute life-threatening hemostatic and/or thrombotic complications, as well as chronic long-standing bleeding or thrombotic issues. Scenarios such as a rapidly growing vascular lesion with severe acute thrombocytopenia, a visceral hemorrhagic lesion, a lesion associated with repetitive and painful superficial thrombosis, and cases of unprovoked or post-procedural fatal pulmonary embolism highlight the wide spectrum of manifestations of abnormal coagulation in patients with vascular anomalies. The separation of vascular anomalies into two distinct groups, vascular tumors and vascular malformations, was followed by the characterization that their respective coagulopathies were due to either a derangement of platelets or to a disequilibrium of the patient's coagulation/fibrinolytic process. This configuration of coagulopathies will be the foundation for this two-chapter review series. In the initial review, coagulopathies where thrombocytopenia is the main feature will be characterized, whereas the second review will focus on vascular malformations that have a coagulation disorder secondary to some degree of coagulation consumption and/or fibrinolytic pathway derangement.

Neutron Skin Effects in Mirror Energy Differences: The Case of ^{23}Mg-^{23}Na

Energy differences between analogue states in the T=1/2 ^{23}Mg-^{23}Na mirror nuclei have been measured along the rotational yrast bands. This allows us to search for effects arising from isospin-symmetry-breaking interactions (ISB) and/or shape changes. Data are interpreted in the shell model framework following the method successfully applied to nuclei in the f_{7/2} shell. It is shown that the introduction of a schematic ISB interaction of the same type of that used in the f_{7/2} shell is needed to reproduce the data. An alternative novel description, applied here for the first time, relies on the use of an effective interaction deduced from a realistic charge-dependent chiral nucleon-nucleon potential. This analysis provides two important results: (i) The mirror energy differences give direct insight into the nuclear skin; (ii) the skin changes along the rotational bands are strongly correlated with the difference between the neutron and proton occupations of the s_{1/2} "halo" orbit.

Shell Evolution towards ^{78}Ni: Low-Lying States in ^{77}Cu

The level structure of the neutron-rich ^{77}Cu nucleus is investigated through β-delayed γ-ray spectroscopy at the Radioactive Isotope Beam Factory of the RIKEN Nishina Center. Ions of ^{77}Ni are produced by in-flight fission, separated and identified in the BigRIPS fragment separator, and implanted in the WAS3ABi silicon detector array, surrounded by Ge cluster detectors of the EURICA array. A large number of excited states in ^{77}Cu are identified for the first time by correlating γ rays with the β decay of ^{77}Ni, and a level scheme is constructed by utilizing their coincidence relationships. The good agreement between large-scale Monte Carlo shell model calculations and experimental results allows for the evaluation of the single-particle structure near ^{78}Ni and suggests a single-particle nature for both the 5/2_{1}^{-} and 3/2_{1}^{-} states in ^{77}Cu, leading to doubly magic ^{78}Ni.

Endovenous laser ablation therapy in children: applications and outcomes

BACKGROUND

Endovenous laser ablation is well recognized as the first-line treatment for superficial venous reflux with varicose veins in adults. It is not widely reported and is not an established practice in pediatric patients.

OBJECTIVE

To illustrate a variety of pediatric venous conditions in which endovenous laser ablation can be utilized and to demonstrate its feasibility and safety in children.

MATERIALS AND METHODS

We conducted a retrospective review of endovenous laser ablation procedures performed between January 2007 and July 2014 at two large pediatric institutions.

RESULTS

We included 35 patients (17 males) who underwent endovenous laser ablation to 43 veins. Median age at first treatment was 14 years (range: 3-18 years). Median weight was 56 kg (range: 19-97 kg). Underlying diagnoses were common venous malformation (15), Klippel-Trenaunay syndrome (8), superficial venous reflux with varicose veins (5), verrucous hemangioma-related phlebectasia (4), venous varix (2) and arteriovenous fistula (1). The most common aim of treatment was to facilitate sclerotherapy. Thirty-four patients had treatment in the lower limbs and one patient in an upper limb. Ten of the veins treated with endovenous laser ablation had an additional procedure performed to close the vein. Complications attributable to endovenous laser ablation occurred in two patients (6%). One patient experienced post-procedural pain and one patient developed a temporary sensory nerve injury. Median clinical follow-up was 13 months (range: 28 days-5.7 years). The aim of the treatment was achieved in 29 of the 35 (83%) patients.

CONCLUSION

Endovenous laser ablation is technically feasible and safe in children. It can be used in the management of a range of pediatric venous diseases with good outcomes.

IR Approaches to Difficult Removals of Totally Implanted Venous Access Port Catheters in Children: A Single-Center Experience

PURPOSE

To identify factors associated with adherence of implanted venous access port catheters in children and describe technical strategies for removing "stuck" ports.

MATERIALS AND METHODS

A retrospective single-center review of port removals was conducted between 2003 and 2012. Cases were identified through radiology reports. Clinical details (eg, demographics, disease, port dwell time, interventional techniques) were obtained through patient charts. Cases were classified as difficult removals if there was documented adherence to soft tissues or vein, or simple removals if no difficulty was recorded. Difficult removals were categorized and graded on increasing invasiveness of techniques required. Successful removal was defined as complete removal of the port catheter. Difficult removals were compared with simple removals for factors associated with difficult removal. Of all removals (N = 1,306), 58 were classified as difficult removals (4%).

RESULTS

Using various techniques, 57 of 58 (98%) adherent port catheters were successfully removed. Factors identified with difficult removals included primary diagnosis of acute lymphoblastic leukemia (ALL) (78% vs 37%, P < .0001), age at insertion (3.7 y vs 5.4 y, P = .0019), and port dwell time (median 1,087 d vs 616 d, P < .0001).

CONCLUSIONS

Difficulty removing port catheters in children is uncommon. Port catheters can usually be removed successfully using various IR techniques ranging in invasiveness. There is an association of difficult removal with early age at insertion, ALL diagnosis, and long port dwell time. Awareness of these factors may help physicians inform parents of potential difficulties and plan the removal procedure.

Quadrupole transition strength in the (74)Ni nucleus and core polarization effects in the neutron-rich Ni isotopes

The reduced transition probability B(E2;0(+)→2(+)) has been measured for the neutron-rich nucleus (74)Ni in an intermediate energy Coulomb excitation experiment performed at the National Superconducting Cyclotron Laboratory at Michigan State University. The obtained B(E2;0(+)→2(+))=642(-226)(+216)  e(2) fm(4) value defines a trend which is unexpectedly small if referred to (70)Ni and to a previous indirect determination of the transition strength in (74)Ni. This indicates a reduced polarization of the Z=28 core by the valence neutrons. Calculations in the pfgd model space reproduce well the experimental result indicating that the B(E2) strength predominantly corresponds to neutron excitations. The ratio of the neutron and proton multipole matrix elements supports such an interpretation.

β-Decay half-lives of 76,77Co, 79,80Ni, and 81Cu: experimental indication of a doubly magic 78Ni

The half-lives of 20 neutron-rich nuclei with Z=27-30 have been measured at the RIBF, including five new half-lives of (76)Co(21.7(-4.9)(+6.5) ms), (77)Co(13.0(-4.3)(+7.2) ms), (79)Ni(43.0(-7.5)(+8.6) ms), (80)Ni(23.9(-17.2)(+26.0) ms), and (81)Cu(73.2 ± 6.8 ms). In addition, the half-lives of (73-75)Co, (74-78)Ni, (78-80)Cu, and (80-82)Zn were determined with higher precision than previous works. Based on these new results, a systematic study of the β-decay half-lives has been carried out, which suggests a sizable magicity for both the proton number Z = 28 and the neutron number N=50 in (78)Ni.

Symptomatic liver involvement in neonatal hereditary hemorrhagic telangiectasia

High-flow hepatic vascular anomalies with arteriovenous shunting commonly manifest during the neonatal period with signs and symptoms of congestive heart failure, but to our knowledge, they have never been described in patients with hereditary hemorrhagic telangiectasia (HHT). We report here our experience with 3 patients with hepatic arteriovenous malformations (AVMs) who presented with symptoms of high-output congestive heart failure during the neonatal period and were subsequently diagnosed with HHT. Imaging showed large hypervascular lesions and multiple hepatic arteriovenous shunts that differentiated these lesions from liver hemangiomas. Transcatheter embolization was performed in all cases. One infant died of sepsis shortly after embolization; follow-up at the age of 2.5 years of the surviving infants revealed involution of the vascular lesions and no evidence of symptom recurrence. We conclude that severe symptoms related to hepatic AVMs in HHT can occur in the neonatal period and that HHT should therefore be included in the differential diagnosis of symptomatic neonatal hepatic vascular malformations. Imaging plays a key role in differentiating hepatic AVMs from hemangiomas, because the latter require additional pharmacologic treatments. Early transcatheter embolization seems to be effective, but long-term outcomes still need to be assessed.

Use and accuracy of US guidance for image-guided injections of the temporomandibular joints in children with arthritis

BACKGROUND

Juvenile idiopathic arthritis (JIA) has an incidence that ranges from 1 to 22 per 100,000 children worldwide, with involvement of the temporomandibular joint (TMJ) in 17-87% of patients. Intraarticular corticosteroid injections are beneficial in the local treatment of JIA and of other types of arthritis.

OBJECTIVE

To describe and assess the accuracy of an US-guided technique for visualization of needle placement within the TMJ in children.

MATERIALS AND METHODS

Between January 2000 and November 2007, 180 TMJ injections were performed during 116 encounters in 83 children with arthritis (71 girls, 12 boys; mean age 12.0 years). Access was obtained under sterile conditions using US guidance (linear 15-MHz or curvilinear 8-MHz transducers) in a coronal plane, and confirmed with CT. To minimize radiation, a limited focused CT protocol was developed.

RESULTS

A bilateral injection was performed in 65 encounters (57%). Twenty-three children had repeat TMJ injections. All injections were performed using US guidance. CT confirmation was used in 127/180 TMJs (70%). In those confirmed with CT, the needle tip was intra-articular in 91% of cases. Triamcinolone hexacetonide was used in 92% of injections and triamcinolone acetonide in 8%. One major complication was encountered (skin atrophy at the injection site).

CONCLUSION

In our experience, TMJ injections using sonographic guidance is a safe, effective and accurate procedure.

Symptomatic caval penetration by a Celect inferior vena cava filter

We report a case of penetration of the inferior vena cava (IVC) by all four primary struts of a Celect caval filter in a 17-year-old girl with Klippel-Trénaunay syndrome. The girl presented with acute lower abdominal and right leg pain 17 days after filter insertion. An abdominal radiograph demonstrated that the filter had moved caudally and that the primary struts had splayed considerably since insertion. Contrast-enhanced CT confirmed that all four primary struts had penetrated the IVC wall. There was a small amount of retroperitoneal hemorrhage. The surrounding vessels and viscera were intact. The filter was subsequently retrieved without complication.

Delayed, life-threatening lower gastrointestinal hemorrhage in an infant after serial transverse enteroplasty: treatment with transcatheter n-butyl-2-cyanoacrylate embolization

We report a case of n-butyl-2-cyanoacrylate glue embolization of life-threatening lower gastrointestinal (LGI) hemorrhage in a 10-month-old boy. The child had a history of gastroschisis and short-bowel syndrome. Six months prior to the LGI bleed, he had undergone a serial transverse enteroplasty (STEP) to lengthen his intestine. To the best of our knowledge this is both the first report of successful glue embolization for LGI bleeding in a child and also the first report of severe hemorrhage after the STEP procedure.

Vesicocutaneous fistula arising from a bladder diverticulum

A 55-year-old man presented with intermittent episodes of urinary leak through the left groin following an abscess drainage at that site at the age of 5 years. Since then he had been suffering from recurrent urinary tract infections and urinary leak, which used to be treated symptomatically. Intravenous urogram (IVU), voiding cystourethrogram (VCU), and cystoscopy done in our institution revealed a bladder diverticulum with a stone in situ, which was communicating with the fistulous opening located in the left groin. Diverticulectomy and excision of the fistulous tract cured the patient. A long-standing fistula arising from a bladder diverticulum at relatively distant site is of extreme rarity. Vesicocutaneous fistula from an iatrogenic injury to vesical diverticulum resulting from a groin surgery has not been reported so far.

Vesicocutaneous fistula arising from a bladder diverticulum

A 55-year-old man presented with intermittent episodes of urinary leak through the left groin following an abscess drainage at that site at the age of 5 years. Since then he had been suffering from recurrent urinary tract infections and urinary leak, which used to be treated symptomatically. Intravenous urogram (IVU), voiding cystourethrogram (VCU), and cystoscopy done in our institution revealed a bladder diverticulum with a stone in situ, which was communicating with the fistulous opening located in the left groin. Diverticulectomy and excision of the fistulous tract cured the patient. A long-standing fistula arising from a bladder diverticulum at relatively distant site is of extreme rarity. Vesicocutaneous fistula from an iatrogenic injury to vesical diverticulum resulting from a groin surgery has not been reported so far.

Early presentation of an extremity arteriovenous malformation

We report a very rare case of a high flow arteriovenous malformation (AVM) of the upper limb that caused high output cardiac failure at birth. There was early transfer of the baby to the care of a multidisciplinary team. After radiological intervention, the arm distal to the malformation became ischaemic and an urgent amputation through the upper-humerus followed. Methods of treatment are discussed, together with a review of results in the literature.

Intraosseous haemangioma of the mandible: a case report

An unusual case of an endangering intraosseous haemangioma affecting the mandible in early childhood is presented. The early diagnosis was unclear until a surgical biopsy was performed. MRI confirmed the diagnosis. Successful emergent arterial embolisation and intralesional steroid injection were undertaken to control troublesome bleeding prior to medical treatment.

Improved technique of portal vein reconstruction in pediatric liver transplant recipients with portal vein hypoplasia

BACKGROUND

Children with small or hypoplastic portal veins represent a challenge for liver transplantation. Graft loss of up to 70% has been reported in these patients in the past. A variety of techniques has been used in both cadaveric and living related transplants in an effort to overcome this problem. Variability arises as to whether to use a vascular graft and where on the portal system to attach the graft.

METHOD

We present our usage of a simple and straightforward interposition iliac vein allograft fashioned in a manner to achieve large anastomotic cross-sectional area on the confluence of the superior mesenteric/splenic veins. The procedure also overcomes problems of graft vein/portal vein size mismatch in the cases where liver and vein grafts are procured from much larger donors.

RESULTS

A total of 14 children presented with hypoplastic portal vein (diameter<5 mm), of a total of 30 consecutive patients requiring cadaveric liver transplants, and benefited from this technique. Median recipient age was 10.5 months. Revascularization times ranged from 22 to 43 min with a mean of 33 min. All patients are alive and well at a mean follow-up of 329 days (10 months). All liver grafts are well and functioning. No portal vein problem was detected.

CONCLUSION

Results from this technique are clearly encouraging. Because portal vein hypoplasia is a common problem in pediatric transplant candidates, we believe this alternative technique is of interest and should be added to the transplant surgeon's armamentarium.

Successful treatment of refractory ascites in a child with transjugular intrahepatic portosystemic shunt

A 16-y-old boy who had undergone bone marrow transplantation for relapsed acute lymphoblastic leukaemia developed liver cirrhosis and refractory ascites, which did not respond to salt restriction, diuretics and abdominal paracentesis. Liver transplantation was not feasible because of poor nutritional status, pre-existing renal dysfunction and uncertainty about the prognosis of his leukaemia. The patient underwent a successful transjugular intrahepatic portosystemic shunt (TIPS), with immediate resolution of ascites, enabling cessation of diuretics and improvement in nutritional status. At 24 mo following TIPS there has been no re-accumulation of ascites.

CONCLUSION

TIPS may have a role in the management of refractory ascites secondary to liver cirrhosis in selected children.

Outcome of liver transplantation in patients with diabetes mellitus: a case-control study

The influence of preexisting diabetes mellitus (DM) on outcome after orthotopic liver transplantation (OLT) has not been well defined. The objective of our study was to compare the morbidity and mortality after OLT in 57 patients with preexisting DM (3 type I, 54 type II) with 114 age-, sex-, and race-matched patients without DM (case controls). The demographics were similar in both groups. Pretransplantation serum creatinine was significantly higher in the diabetic group compared with case controls. The incidence of the following complications was significantly higher in the diabetic group after OLT: cardiovascular (61.4% vs. 21.9%, P <.001), major (54.4% vs. 29.8%, P =.002) and minor infections (29.8% vs. 7.9%, P <.0001), renal (59.7% vs. 20.2%, P <.001), ophthalmologic (10.5% vs. 0.9%, P =.01), respiratory (24.6% vs. 7.0%, P =.001), neurologic (31.6% vs. 7.0%, P <.001), hematologic (19.3% vss 2.6%, P =.001), musculoskeletal (24.6% vs. 5.3%, P =.001), and malignancy (22.8% vs. 10.5%, P =.03). The duration of hospital stay, cost of hospitalization, retransplantation, and overall graft survival were similar. Acute rejection was seen in 50.9% of diabetics compared with 25.4% in controls (P =.0009). One-year (87% vs. 77%) and 2-year (81.6% vs. 70.1%) patient survival was similar, but 5-year survival was lower in the DM group (34.4% vs. 67.7%, P =.002). In conclusion, preexisting diabetes is associated with a significant post-OLT morbidity and mortality, and our observations suggest that patients with DM warrant more rigorous pre- and post-OLT evaluation.

A familial case of pulmonary arterial sequestration

The cases of a mother and infant son are reported, both with a rare type of pulmonary sequestration where the arterial supply to the lung arises from the systemic circulation. This is a familial case of arterial sequestration. In both patients, the lung parenchyma was radiologically normal.

Intervention for pleural effusions and ascites following liver transplantation

BACKGROUND

Small volumes of fluid in the pleural and peritoneal cavities are common after paediatric liver transplantation. Occasionally, larger fluid collections develop and need intervention by aspiration or insertion of a drain. Objective. To assess the incidence of moderate and large pleural and peritoneal fluid collections following paediatric liver transplantation, the need for intervention and the outcome following radiological and non-radiological treatment, with the ultimate objective of recommending a treatment protocol for such post-operative fluid collections.

MATERIALS AND METHODS

A total of 184 consecutive liver grafts in 164 children were reviewed.

RESULTS

Of 184 grafts, 31 (16.8%) developed excessive fluid collections requiring intervention (19 pleural effusions, 8 ascites and 4 effusions and ascites). The effusions were first diagnosed between days 1 and 44 after transplant and the ascites between days 1 and 14. The initial diagnosis was made radiologically in 21 (91%) of 23 pleural effusions and in 10 (83%) of 12 ascites. No identifiable cause or association was seen in 18 (58%) of 31 cases. The mean duration of the pleural effusions and ascites, from onset of treatment to resolution, ranged from 33 +/- 42 days (SD) to 35 +/- 48 days and from 36 +/- 47 days to 39 +/- 46 days respectively. Comparison of the modes of interventional treatment (i.e. unguided, radiological and surgical) showed no statistically significant difference in the outcome of the management.

CONCLUSIONS

Post-transplantation pleural effusions and ascites requiring intervention are often without definite cause. They are more common with reduced grafts, but this cannot completely explain the occurrence or the protracted duration of accumulation in spite of combined interventional management. The outcome of treatment is not significantly influenced by the mode of intervention except in cases where surgical intervention is indicated. Patients could be managed effectively without resorting to chronic outpatient aspiration. US contributed significantly in the initial and follow-up evaluation of these patients, even in cases of pleural effusions, and we would recommend greater use of US in place of radiographs to reduce the radiation burden when fluid collections are protracted.

US demonstration and diagnosis of the midaortic syndrome

The midaortic syndrome is a rare entity, typically presenting with hypertension, refractory to treatment. The diagnosis is usually made by arteriography. We report a child in whom the diagnosis was made by ultrasound, confirmed by arteriography and successfully treated by balloon dilatation.

Hypertension secondary to progressive vascular neurofibromatosis

A 4 year old girl with neurofibromatosis type 1 (NF1) was referred for hypertension. An aortogram showed narrowing of the left main renal artery. An angiogram three and a half years later showed coarctation of the abdominal aorta. She underwent aortoplasty but the stenosis recurred. Vascular involvement in NF1 may be progressive and requires long term follow up.

Technical aspects of insertion and removal of an inferior vena cava IVC filter for prophylactic treatment of pulmonary embolus

We report the successful insertion and subsequent retrieval of a Gunther-Tulip vena cava filter in a patient with an anomalous left-sided inferior vena cava, who developed a right ilio-femoral venous thrombosis prior to planned surgical resection of a right femoral osteosarcoma. The indication was for short-term prophylaxis against pulmonary embolism during manipulative leg surgery.

Percutaneous retrieval of a fractured biliary guidewire from a reduced liver graft

We describe a unique case of percutaneous retrieval of a broken guidewire in the biliary tree of a patient with a biliary stricture following liver transplantation with a reduced segment 2,3 graft using an Amplatz "goose-neck" snare.

Temporary balloon occlusion of the inferior vena cava as an alternative to cardiopulmonary bypass in resection of Wilms' tumour with vena cava extension

Up to 10% of patients undergoing nephrectomy for Wilms' tumour have tumour thrombus involving the vena cava. A new radiological technique is described utilising a temporary occlusion balloon inserted via an open venotomy of the left internal jugular vein into the retro-hepatic cava to create a bloodless field to facilitate surgery.

Power Doppler ultrasound appearances of neonatal ischaemic brain injury

Following neonatal ischaemic brain injury, irregular vessels increase in size owing to luxury perfusion. These may be demonstrated by conventional colour flow Doppler (CFD) imaging at the periphery of the infarcted area. We present a case in which power Doppler imaging (PDI) was performed in addition to CFD in a neonate with unexplained seizures and which proved more sensitive than CFD in demonstrating luxury perfusion. Ultrasound appearances were compared with those seen on cranial CT. PDI can be a useful adjunct to conventional CFD examination of the neonatal brain in cerebral infarction.

Metallic stenting of the biliary tree following liver transplant hepatic artery thrombosis in an infant

We report the placement of intrahepatic metallic, balloon-expandable stents in the biliary tree following liver transplantation in a 12-month-old infant who developed biliary strictures secondary to hepatic artery thrombosis. The use of such stents has not previously been reported following transplantation in an infant. Re-transplantation was undertaken 5 months after stenting because of chronic rejection and progressive obstructive jaundice.

Emergency transjugular intrahepatic portosystemic shunt prior to liver transplantation

Transjugular intrahepatic portosystemic shunt (TIPSS) is a new development in the management of severe variceal haemorrhage which has been established in adult patients. We have successfully adapted this technique for children and describe our initial experience in the case of a 9-year-old boy who presented with acute and chronic liver failure and uncontrollable life-threatening bleeding from oesophageal and gastric varices, despite intensive medical management including sclerotherapy. A 10-mm TIPSS was successfully placed with immediate reduction in portal pressure and cessation of variceal bleeding. The patient's condition stabilised sufficiently for him to undergo liver transplantation 2 days later, at which time the TIPSS was patent.

Imaging of biliary complications following paediatric liver transplantation

Biliary complications (BC) are well recognised following paediatric liver transplantation. We reviewed retrospectively 169 consecutive liver transplants performed in 139 children. BC occurred in 36/169 grafts (21 %) in 35/139 patients (25 %). Biliary obstruction was present in 18/169 grafts (11 %), biliary leakage in 14/169 grafts (8 %) and a combination of obstruction and leakage was present in 4/169 (2 %) grafts. BC were as likely to present radiologically as they were with either clinical and/or biochemical abnormalities. Most BC (26/36, i. e. 72 %) occurred in the first 2 weeks following transplantation. Ultrasound and cholangiography were the principle imaging modalities used for detection of these complications. False negative ultrasound examinations occurred in three patients with biliary obstruction and in three patients with biliary leakage. False negative cholangiograms occurred in two patients with biliary leakage. Ultrasound is important in the post-operative surveillance of paediatric liver transplants, with cholangiography having a complementary role in those with BC.

Bone fractures in children undergoing orthotopic liver transplantation

This retrospective study documents the incidence and distribution of fractures in 117 children with end-stage liver disease who underwent orthotopic liver transplantation (OLT) over a 6-year period (1987-1993). Both the pre- and post-OLT phases were included. Nineteen children (16.2 %) sustained a total of 69 fractures. Age at time of fracture ranged from 3 months to 9 years 8 months (median 13.5 months). There was no documented trauma in 14/19 cases. Metabolic bone disease, assessed qualitatively on plain radiographs, was present in 17/19 children at the time of fracture. This took the form of rickets (n = 3), osteopenia (n = 12) and osteosclerosis (n = 2). Potential risk factors including pre-existing metabolic bone disease, drugs and immobilization were assessed. The findings emphasise the need for clinical and radiological awareness of the fracture risk, particularly during the peri-transplant period when this risk may be greatest.

Early childhood presentation of neurovascular disease in hereditary haemorrhagic telangiectasia

This paper describes an unusual case of hereditary haemorrhagic telangiectasia related cerebrovascular disease with an arteriovenous malformation and aneurysm presenting with intracranial haemorrhage in early childhood.

Bilateral congenital lacrimal sac mucoceles with nasal extension

This paper describes the CT findings in a case of bilateral congenital lacrimal sac mucoceles in a full-term infant. The patient was also found to have a unilateral choanal stenosis.

Pulmonary sequestration and related congenital disorders. A clinico-radiological review of 41 cases

Forty-one children with pulmonary sequestration complex were reviewed. This disease is a spectrum of disorders involving the bronchopulmonary airway, the arterial supply to the lungs, the lung parenchyma and its venous drainage. The review showed pulmonary sequestration to be ubiquitous in its presentation: "classical" features of sequestration occurred in 20 (49%) children studied. The early diagnosis of children with sequestration outside infancy demands a high index of suspicion by the radiologist. The role of angiography in demonstrating an anomalous systemic arterial supply to the lung in suspected bronchial and pulmonary arterial sequestration is described in relation to alternative imaging techniques available.