Publications by authors named "Prakash Muthusami"

45 Publications

Use of radial access sheaths for transfemoral neuroendovascular procedures in children.

Neuroradiology 2021 Apr 9;63(4):633-635. Epub 2021 Feb 9.

Divisions of Neuroradiology and Image Guided Therapy, Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, ON, M5G 1X8, Canada.

Purpose: Pediatric neuroendovascular procedures require special considerations. Given small vessel sizes, risk for arterial injury must be weighed against use of larger devices, with the diameter of the sheath being a known association with arterial complications. We recently transitioned to using thin-walled radial sheaths for transfemoral angiography in children, given their lower profile. Here, we report on these sheaths' technical success and complications, comparing against a historical cohort where regular vascular sheaths were employed.

Methods: We retrospectively recorded patient and procedural data from 168 consecutive procedures from September 2017 to January 2019 when radial-specific sheaths were exclusively used at our tertiary pediatric hospital. These results were compared to data from September 2015 to January 2017, when regular vascular sheaths were exclusively used in 152 consecutive procedures. Statistical analysis was performed using unpaired t test or chi-square test, with p < 0.05 considered statistically significant.

Results: Patient characteristics (age, sex, weight) were not statistically different between the case and control group. No significant differences were found in the procedural data with the exception of heparin use which was higher in the radial-sheath cohort. There was a decrease in the rate of complications in the case group (1.2%) versus control group (2.6%), though not statistically different.

Conclusion: Radial-specific sheaths have numerous beneficial characteristics that make them well-suited to the pediatric population. In our study, we show that radial sheaths are equally effective and safe perioperatively. Follow-up research may show if radial sheaths used transfemorally decrease long-term complications such as limb-length discrepancy and mortality.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00234-021-02664-4DOI Listing
April 2021

Image-guided chest tube drainage in the management of chylothorax post cardiac surgery in children: a single-center case series.

Pediatr Radiol 2021 May 30;51(5):822-830. Epub 2021 Jan 30.

Image Guided Therapy, Diagnostic Imaging, The Hospital for Sick Children, 555 University Ave., Toronto, ON, M5G 1X8, Canada.

Background: In children, chylothorax post cardiac surgery can be difficult to treat, may run a protracted course, and remains a source of morbidity and mortality.

Objective: To analyze the experience with percutaneous image-guided chest-tube drainage in the management of post-cardiac-surgery chylothoraces in children.

Materials And Methods: We conducted a single-center retrospective case series of 37 post-cardiac-surgery chylothoraces in 34 children (20 boys; 59%), requiring 48 drainage procedures with placement of 53 image-guided chest tubes over the time period 2004 to 2015. We analyzed clinical and procedural details, adverse events and outcomes. Median age was 0.6 years, median weight 7.2 kg.

Results: Attempted treatments of chylothoraces prior to image-guided chest tubes included dietary restrictions (32/37, 86%), octreotide (12/37, 32%), steroids (7/37, 19%) and thoracic duct ligation (5/37, 14%). Image-guided chest tubes (n=43/53, 81%) were single unilateral in 29 children, bilateral in 4 (n=8/53, 15%), and there were two ipsilateral tubes in one (2/53, 4%). Effusions were isolated, walled-off, in 33/53 (62%). In 20/48 procedures (42%) effusions were septated/complex. The mean drainage through image-guided chest tubes was 17.3 mL/kg in the first 24 h, and 13.4 mL/kg/day from diagnosis to chest tube removal; total mean drainage from all chest tubes was 19.6 mL/kg/day. Nine major and 27 minor maintenance procedures were required during 1,207 tube-days (rate: 30 maintenance/1,000 tube-days). Median tube dwell time was 21 days (range 4-57 days). There were eight mild adverse events, three moderate adverse events and no severe adverse events related to image-guided chest tubes. Radiologic resolution was achieved in 26/37 (70%). Twenty-three children (68%) survived to discharge; 11 children (32%) died from underlying cardiac disease.

Conclusion: Management of chylothorax post-cardiac-surgery in children is multidisciplinary, requiring concomitant multipronged approaches, often through a protracted course. Multiple image-guided chest tube drainages can help achieve resolution with few complications. Interventional radiology involvement in tube care and maintenance is required. Overall, mortality remains high.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00247-020-04928-2DOI Listing
May 2021

Surgical management of pediatric rolandic arteriovenous malformations: a single-center case series.

J Neurosurg Pediatr 2020 Oct 30:1-7. Epub 2020 Oct 30.

1The Hospital for Sick Children, Toronto.

Objective: Pediatric rolandic arteriovenous malformations (AVMs) present a treatment challenge given the lifetime risk of hemorrhage, rehemorrhage, and associated long-term morbidity. Microsurgical resection has been recommended as the optimal treatment for AVMs in general, but there is no dedicated literature on the outcomes of resection of pediatric rolandic AVMs. Here, the study objective was to review the outcomes of microsurgical resection of pediatric rolandic AVMs in the modern era, together with the utilization of surgical adjuncts including navigation, intraoperative angiography, and neurophysiological monitoring.

Methods: The authors performed a retrospective review of patients 18 years of age and younger with cerebral AVMs microsurgically treated between January 2000 and May 2016 at The Hospital for Sick Children. Only those patients with an AVM whose nidus was located within the rolandic region were analyzed. A descriptive analysis was performed to identify patient demographics, preoperative AVM characteristics, and postoperative obliteration rates and neurological complications.

Results: A total of 279 AVMs were evaluated in the study period. Twenty-three of these AVMs were rolandic, and the median age in the 11 microsurgically treated cases was 11 years (range 1-17 years). AVM hemorrhage was the most common presentation, occurring in 8 patients (73%). Lesions were either Spetzler-Martin grade II (n = 8, 73%) or grade III (n = 3, 27%). The postoperative obliteration rate of AVMs was 100%. The mean imaging follow-up duration was 33 months (range 5-164 months). There was no documented recurrence of an AVM during follow-up. One patient developed a transient postoperative hemiparesis, while another patient developed right fingertip hyperesthesia.

Conclusions: Microsurgical resection of rolandic pediatric AVMs yields excellent AVM obliteration with minimal neurological morbidity in selected patients. The incorporation of surgical adjuncts, including neurophysiological monitoring and neuronavigation, allows accurate demarcation of functional cortex and enables effective resection.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3171/2020.6.PEDS18547DOI Listing
October 2020

Radiation-induced intracranial aneurysm presenting with acute hemorrhage in a child treated for medulloblastoma.

Childs Nerv Syst 2021 Apr 9;37(4):1387-1389. Epub 2020 Aug 9.

Department of Diagnostic Imaging, Division of Neuroradiology, The Hospital for Sick Children, University of Toronto, 555 University Ave, Toronto, ON, M5G 1X8, Canada.

Radiation-associated aneurysms are rare, difficult to treat, and associated with high morbidity and mortality when ruptured, compared with aneurysms unrelated to radiation treatment. We present a 16-year-old patient with a radiation-induced intracranial aneurysm arising from the left posterior inferior cerebellar artery (PICA), 10 years following radiotherapy for medulloblastoma. The patient successfully underwent endovascular coil embolization of the parent artery across the neck of the aneurysm. CT angiography and MRI in the days following the procedure demonstrated maintained flow in the anterior and lateral medullary PICA segments with no brainstem infarct.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00381-020-04853-7DOI Listing
April 2021

Can Children Be Considered for Transradial Interventions?: Prospective Study of Sonographic Radial Artery Diameters.

Circ Cardiovasc Interv 2020 07 2;13(7):e009251. Epub 2020 Jul 2.

Department of Image Guided Therapy (A.A., W.H., S.B., A.A.D., K.B., P.M.), The Hospital for Sick Children, University of Toronto, ON, Canada.

Background: Transradial intervention is increasingly replacing approaches, due to lower access complications, cost, and improved patient satisfaction. There are limited supporting data in the pediatric literature, largely due to concerns regarding arterial size. The objective of this study was to measure radial artery diameters in children across all age groups, to establish reference ranges for clinical use.

Methods: This prospective study was carried out in children ≤18 years of age who underwent ultrasound for measuring radial artery diameters from November 2018 to November 2019. The cohort was divided into age groups: ≤2, 3 to 5, 6 to 8, 9 to 11, 12 to 14, 15 to 18 years, and into pre- and post-adolescent (≥12 years) groups.

Results: One hundred thirty-four children (M:F=63:71) were included, with bilateral measurements resulting in 268 data points. Mean age was 8.9±5.8 years (range, 29 days to 18 years), mean weight 37.2±27.5 kg (range, 1.7-149.1 kg). Mean-corrected radial artery diameter was 1.86±0.44 mm. There was no difference in arterial diameters between males and females (1.90±0.50 versus 1.81±0.53 mm; =0.73) or between right and left sides (1.87±0.46 versus 1.87±0.47, =0.98). There was a strong correlation of diameter with age (R=0.75; <0.00001) and weight (R=0.74; <0.00001). There was linear increase in arterial growth rates in early childhood, followed by plateauing to adult sizes in adolescents. Inter-reader agreement was 0.95.

Conclusions: We provide a reference range for radial artery diameters across childhood ages, which can be used for decision-making. This could be the basis for designing a trial of transradial intervention in children, to establish clinical safety and efficacy.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/CIRCINTERVENTIONS.120.009251DOI Listing
July 2020

Image guided sacroiliac joint corticosteroid injections in children: an 18-year single-center retrospective study.

Pediatr Rheumatol Online J 2020 Jun 17;18(1):52. Epub 2020 Jun 17.

Division of Image Guided Therapy, Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.

Background: Sacroiliitis is commonly seen in enthesitis-related arthritis (ERA), a subtype of juvenile idiopathic arthritis (JIA). Sacroiliitis is characterized by the inflammation of the sacroiliac (SI) joints (+/- adjacent tissues). The treatment options include systemic therapy with or without corticosteroid SI joint injections. Image guided SI joint injections are frequently requested in pediatric patients with sacroiliitis. The purpose of this study was to evaluate the feasibility and efficacy of SI joint injections in children with sacroiliitis.

Methods: A retrospective study of patients referred to Interventional Radiology (IR) for SI joint corticosteroid injections (2000-2018). Clinical information was collected from Electronic Patient Charts and procedural details from PACS. Efficacy was determined clinically, by MRI, or both when available.

Results: 50 patients (13.8 years; M:F = 35:15) underwent image-guided SI joint corticosteroid injections. Most common indications were JIA (84%) and inflammatory bowel disease (14%). 80% had bilateral injections. 80% were performed under general anesthesia and 20% under sedation. The corticosteroid of choice was triamcinolone hexacetonide in 98% of patients. Needle guidance and confirmation was performed using CT and fluoroscopy (54%), Cone Beam CT (CBCT, 46%), with initial ultrasound assistance in 34%. All procedures were technically successful without any complications. 32/50 patients had long-term follow-up (2 years); 21/32 (66%) had clinical improvement within 3-months. Of 15 patients who had both pre- and post-procedure MRIs, 93% showed short-term improvement. At 2 years, 6% of patients were in remission, 44% continued the same treatment and 47% escalated treatment.

Conclusion: Image-guided SI joint injections are safe and technically feasible in children. Imaging modalities for guidance have evolved, with CBCT being the current first choice. Most patients showed short-term clinical and imaging improvement, requiring long-term maintenance or escalation of medical treatment.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12969-020-00435-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7301971PMC
June 2020

Deep venous communication in vein of Galen malformations: incidence, Imaging, and Implications for treatment.

J Neurointerv Surg 2021 Mar 16;13(3):290-293. Epub 2020 Jun 16.

Department of Image Guided Therapy, Hospital for Sick Children, Toronto, Ontario, Canada.

Background: Failure to appreciate deep venous drainage pathways is a major cause of severe complications in the endovascular treatment of vein of Galen aneurysmal malformations (VOGMs).

Objective: To report deep venous drainage patterns in patients with VOGM, emphasizing the internal cerebral veins, and to describe the challenges in evaluating these.

Methods: Patients with VOGM presenting to our institute between 2000 and 2018 were retrospectively analyzed. Patients with complete and good quality imaging datasets were included in the study. Three neuroradiologists with expertise in the subject independently analyzed the deep venous drainage patterns on multi-sequence MRI and digital subtraction angiography. Follow-up imaging studies were analyzed for alterations in deep venous drainage patterns that occurred following endovascular treatment. Descriptive statistics were used to report findings.

Results: Twenty-three patients had optimal quality MRI imaging and 25 had optimal quality DSA imaging available. In 14/23 (61%) patients, internal cerebral vein (ICV) communication could be reliably identified on MRI and in 8/25 (32%) patients on DSA. Deep venous communication with the VOGM was demonstrated in 8/26 (30.8%) patients. One (3.8%) patient demonstrated ICV communication with the VOGM only on postoperative imaging, while in 2 (8%) patients the ICV drainage route changed from VOGM to alternative pathways after the procedure. Other variant pathways included lateral mesencephalic vein, superior or inferior sagittal sinus, anterior mesencephalic vein, tentorial sinus, deep Sylvian vein, and superior vermian vein.

Conclusion: ICV communication with the VOGM is not uncommon and requires dedicated preprocedural imaging to identify it. However, there are significant challenges in assessing this communication in the presence of high-flow fistulae, vessel tortuosity and size, and contrast limitations in this population.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/neurintsurg-2020-016224DOI Listing
March 2021

Bow hunter syndrome: A rare yet important etiology of posterior circulation stroke.

J Clin Neurosci 2020 Aug 7;78:418-419. Epub 2020 Jun 7.

Division of Neurology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada.

A6-year-oldgirl presented with acute-onset headache andfluctuating right-sided weakness.HerPedNIHSSwas13. Brain MRI/MRA showed acute pontine arterial ischemic stroke(AIS)and remote right cerebellar and thalamic infarcts.No antecedent trauma or other stroke risk factors were identified. Clinical suspicion of bow hunter syndromewas raised. CTshowed congenital C2-C3 fusion and dynamic angiogramconfirmed the diagnosis. The management challenges of this rare condition are discussed below.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jocn.2020.04.110DOI Listing
August 2020

Treatment Strategies and Related Outcomes for Brain Arteriovenous Malformations in Children: A Systematic Review and Meta-Analysis.

AJR Am J Roentgenol 2020 08 6;215(2):472-487. Epub 2020 Jun 6.

Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, 555 University Ave, Toronto, ON M5G 1X8, Canada.

The objective of this study was to assess the available evidence in the literature regarding treatment outcomes for pediatric patients with brain arteriovenous malformation (bAVM) with the aim of providing practice guidelines for treatment decisions and highlighting research areas that need attention. Keyword searches for studies published from January 1, 1981, to April 16, 2018, were performed in MEDLINE, Embase, and Web of Science. Predefined inclusion criteria were used to identify studies. Poisson regression analysis for associations between patient and bAVM characteristics and treatment outcomes. We identified 34 articles comprising 2158 children with bAVM who underwent treatment or observation. The mean age of the study cohort was 12.0 ± 1.6 (SD) years, and 48.1% of the patients were female; 64.3% of bAVMs were hemorrhagic at presentation. The mean follow-up was 50.6 ± 32.3 months. Overall, the meta-analysis of pooled data showed an obliteration rate of 69.8% (95% CI, 62.9-75.9%), recurrence rate of 2.2% (95% CI, 1.1-4.3%), and mortality rate of 2.4%. The pooled complication rate was 22.5% (95% CI, 15.7-31.1%) after surgery, 26.4% (95% CI, 15.2-41.9%) after embolization, and 27.1% (95% CI, 18.1-38.4%) after radiosurgery. Mortality was not associated with age, sex, or hemorrhage; however, recurrence after treatment was inversely associated with age. Complication and mortality rates were reduced for multimodal treatments. For patients with bAVM treated with observation only, complication and mortality rates were 35.9% and 23.5%, respectively. Multimodality treatments for pediatric bAVM had lower mortality and complication rates than individual treatments. However, there is a lack of evidence for long-term outcomes. The mortality rate was highest in conservatively managed patients (i.e., observation only). Further research directly comparing different treatment modalities for recurrence and complications is warranted. Gathering data prospectively through multiinstitutional registries will be key to provide strong evidence.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2214/AJR.19.22443DOI Listing
August 2020

Correction to: Venous pathologies in paediatric neuroradiology: from foetal to adolescent life.

Neuroradiology 2020 Jul;62(7):903

Monash Imaging, Monash Health, Melbourne, Australia.

The original version of this article unfortunately contained a referencing omission. Figure 11 is reused from the original publication of Figure 10 of Gunny and Lin [1].
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00234-020-02443-7DOI Listing
July 2020

The role of MRA in pediatric sickle cell disease with normal transcranial Doppler imaging velocities.

J Stroke Cerebrovasc Dis 2020 Jul 10;29(7):104864. Epub 2020 May 10.

Pediatric Neuroradiology and Image Guided Therapy, Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto M5G 1H4, ON, Canada.

Purpose: The purpose of this study was to determine the additional information provided by Magnetic Resonance Angiography (MRA) in pediatric sickle cell disease (SCD) patients with normal Transcranial Doppler imaging (TCDI) examinations.

Methods: This cohort study included all pediatric SCD patients over an 18-year period who had no history of stroke and had normal TCDI examinations and subsequently underwent MRA. Routine TCDI inclusive of time-averaged mean of maximum velocities (TAMMV) were assesses and compared with tortuosity on MRA and silent infarct on MRI.

Results: 86 children (52.3% female; mean age 8.7 ± 3.5years) were included. There were 77 patients (89.5%) with Hb-SS disease and 9(10.4%) with HB-S beta-thalassemia. All patients had normal TAMMV (<170 cm/s) on TCDI. 76/86 (88.3%) patients also had one or more velocity readings <70 cm/s, albeit none in the middle cerebral arteries. Posterior cerebral arteries had the lowest velocities, <70 cm/s in 51.7% (right) and 60.9% (left). Silent MRI infarcts were seen in 27/86 (31.4%) patients. No new lesions were identified on follow-up MRI. Although mild vascular tortuosity was appreciated in 31/86 (36.0%) of the patients, there were no steno-occlusive lesions in the circle of Willis.

Conclusions: TCDI and MRA are routinely performed for non-invasively evaluating intracranial vascular abnormalities in children with SCD. In SCD children with no history of TIA or stroke, MRA following a normal TCDI examination is unlikely to show vascular abnormality. However, almost a third of these patients show silent infarcts on MRI, unassociated with MRA changes.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2020.104864DOI Listing
July 2020

Factors Contributing to Major Neurological Complications From Vein of Galen Malformation Embolization.

JAMA Neurol 2020 08;77(8):992-999

Image-Guided Therapy, Hospital for Sick Children, Toronto, Ontario, Canada.

Importance: Major neurological complications from the embolization of vein of Galen malformations (VOGMs) are poorly understood. We provide a detailed analysis of contributors to periprocedural neurological complications and lessons learned.

Objective: To assess the rate of major periprocedural neurological complications following VOGM embolization with major procedural and strategic contributors.

Design, Setting, And Participants: This retrospective cohort study was conducted at a quarternary referral pediatric hospital (Hospital for Sick Children; Toronto, Ontario, Canada) from January 1999 to December 2018 with a mean clinical follow-up of 44.7 months; all children with VOGM diagnosed and/or treated were eligible (n = 48). Thirty-three patients who underwent endovascular treatment were included.

Interventions: Endovascular staged transarterial embolization performed in 33 patients over 91 sessions.

Main Outcomes And Measures: The primary outcome was the rate of periprocedural neurological complications (occurring within 1 week of embolization). The secondary outcomes were mortality, long-term neurological outcomes, and contributing anatomical and management factors to neurological complications.

Results: Of 33 patients who underwent embolization (31 boys [64.6%]; 17 girls [35.4%]; median age at first embolization, 4 months [range, 0-29 months]), 10 patients (30.3%) developed major periprocedural neurological complications. Five of these patients died. Univariate logistic regression analyses identified internal cerebral vein drainage to the main venous sac of the VOGM and use of a microcatheter with a distal outer diameter of more than 2.0F as significant predictors of poor neurological outcomes. Lessons learned from our experience include the need to assess the internal cerebral vein drainage pattern on preprocedural magnetic resonance venography, avoidance of excessive embolization into the venous sac, treatment of more distal fistulae before proximal fistulae to avoid a sump effect, and preferably use of smaller (<2.0F outer diameter) microcatheters in neonatal embolization procedures.

Conclusions And Relevance: In this cohort, 10 patients with VOGM treated with embolization (30.3%) experienced major periprocedural neurological complications, half of whom died. While these outcomes are superior to historic conservative and surgical treatment results, ongoing improvements in treatment and pretreatment diagnostic approaches are needed. Awareness of the lessons learned from our experience can help to avoid similar complications in the future for this vulnerable population.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jamaneurol.2020.0825DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7186914PMC
August 2020

Venous pathologies in paediatric neuroradiology: from foetal to adolescent life.

Neuroradiology 2020 Jan 9;62(1):15-37. Epub 2019 Nov 9.

Monash Imaging, Monash Health, Melbourne, Australia.

The interpretation of cerebral venous pathologies in paediatric practice is challenging as there are several normal anatomical variants, and the pathologies are diverse, involving the venous system through direct and indirect mechanisms. This paper aims to provide a comprehensive review of these entities, as their awareness can avoid potential diagnostic pitfalls. We also propose a practical classification system of paediatric cerebral venous pathologies, which will enable more accurate reporting of the neuroimaging findings, as relevant to the underlying pathogenesis of these conditions. The proposed classification system comprises of the following main groups: arterio-venous shunting-related disorders, primary venous malformations and veno-occlusive disorders. A multimodal imaging approach has been included in the relevant subsections, with a brief overview of the modality-specific pitfalls that can also limit interpretation of the neuroimaging. The article also summarises the current literature and international practices in terms of management options and outcomes in specific disease entities.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00234-019-02294-xDOI Listing
January 2020

Locations, associations and temporal evolution of intracranial arterial infundibular dilatations in children.

J Neurointerv Surg 2020 May 7;12(5):495-498. Epub 2019 Nov 7.

Department of Diagnostic Imaging & Image Guided Therapy, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.

Background: There are few data in the literature on the characteristics and natural history of intracranial arterial infundibular dilatations in children.

Methods: An institutional review board-approved retrospective review was performed of infundibula reported on MR angiography in patients <18 years of age at our tertiary pediatric institute from 1998 to 2016. Clinical data (age, sex, diagnosis, other vascular variants/pathologies) were recorded and images assessed for vessel of origin, infundibulum size and exact location. Ratios of infundibulum:parent artery were assessed at diagnosis and last follow-up. Temporal evolution to aneurysm was evaluated.

Results: We found 60 intracranial infundibula in 60 children (male:female=27:33; mean age 9.7±5.2 years, range 2-18 years,). Family history of aneurysms was present in 2/60 (3.3%). Syndromic association was found in 14/60 (23.3%), most frequently sickle cell disease (4/14=28.6%). Mean infundibulum size was 2.2±0.5 mm, with mean ratio to parent artery of 0.54±0.17. The most common location was on the P1-posterior cerebral artery (34/63=56.7%), whereas posterior communicating infundibula were seen in only 4/60 (6.7%) cases. Other cerebrovascular variants were seen in 12/60 (20%) patients. On follow-up imaging (in 32/60 patients over 86 patient-years, mean 32.3±35.7 months), no significant change in infundibulum:parent artery ratio was noted. None of the infundibular dilatations showed interval evolution to aneurysm.

Conclusion: We present the largest reported cohort of pediatric intracranial arterial infundibula, which we found to be distinct from their adult counterparts with regard to location, etiology and temporal evolution. Growth over time and/or aneurysmal formation are rare, not necessitating frequent short-term imaging surveillance during childhood.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/neurintsurg-2019-015433DOI Listing
May 2020

Management of a Large Congenital Hemangioma Obstructing Visual Axis: A Case Report and Review of Literature.

Ophthalmic Plast Reconstr Surg 2019 Nov/Dec;35(6):e154-e157

Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada.

Congenital hemangiomas comprise a subset of vascular tumors with clinicopathologic features that are distinct from the more common infantile hemangioma. The authors present a patient with a large congenital hemangioma involving the forehead and brow which obstructed the visual axis and created significant risk for deprivational amblyopia. Management of the congenital hemangioma involved customized headgear to clear the visual axis and early vascular embolization of feeder vessels with the subsequent successful surgical resection at 23 days of life.A large amblyogenic congenital hemangioma required a multidisciplinary approach involving early vascular embolization of feeder vessels and subsequent surgical resection at 23 days of life.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/IOP.0000000000001490DOI Listing
January 2020

Mechanical thrombectomy in pediatric stroke: systematic review, individual patient data meta-analysis, and case series.

J Neurosurg Pediatr 2019 Aug 9:1-14. Epub 2019 Aug 9.

1Department of Neuroradiology, Toronto Western Hospital.

Objective: The role of mechanical thrombectomy in pediatric acute ischemic stroke is uncertain, despite extensive evidence of benefit in adults. The existing literature consists of several recent small single-arm cohort studies, as well as multiple prior small case series and case reports. Published reports of pediatric cases have increased markedly since 2015, after the publication of the positive trials in adults. The recent AHA/ASA Scientific Statement on this issue was informed predominantly by pre-2015 case reports and identified several knowledge gaps, including how young a child may undergo thrombectomy. A repeat systematic review and meta-analysis is warranted to help guide therapeutic decisions and address gaps in knowledge.

Methods: Using PRISMA-IPD guidelines, the authors performed a systematic review of the literature from 1999 to April 2019 and individual patient data meta-analysis, with 2 independent reviewers. An additional series of 3 cases in adolescent males from one of the authors' centers was also included. The primary outcomes were the rate of good long-term (mRS score 0-2 at final follow-up) and short-term (reduction in NIHSS score by ≥ 8 points or NIHSS score 0-1 at up to 24 hours post-thrombectomy) neurological outcomes following mechanical thrombectomy for acute ischemic stroke in patients < 18 years of age. The secondary outcome was the rate of successful angiographic recanalization (mTICI score 2b/3).

Results: The authors' review yielded 113 cases of mechanical thrombectomy in 110 pediatric patients. Although complete follow-up data are not available for all patients, 87 of 96 (90.6%) had good long-term neurological outcomes (mRS score 0-2), 55 of 79 (69.6%) had good short-term neurological outcomes, and 86 of 98 (87.8%) had successful angiographic recanalization (mTICI score 2b/3). Death occurred in 2 patients and symptomatic intracranial hemorrhage in 1 patient. Sixteen published thrombectomy cases were identified in children < 5 years of age.

Conclusions: Mechanical thrombectomy may be considered for acute ischemic stroke due to large vessel occlusion (ICA terminus, M1, basilar artery) in patients aged 1-18 years (Level C evidence; Class IIb recommendation). The existing evidence base is likely affected by selection and publication bias. A prospective multinational registry is recommended as the next investigative step.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3171/2019.5.PEDS19126DOI Listing
August 2019

Evaluation of implanted venous port-a-caths in children with medical complexity and neurologic impairment.

Pediatr Radiol 2019 09 13;49(10):1354-1361. Epub 2019 Jul 13.

Image Guided Therapy Centre, Diagnostic Imaging Department, The Hospital for Sick Children, 555 University Ave., Toronto, ON, M5G 1X8, Canada.

Background: Children with medical complexity and associated neurologic impairment frequently face difficulties with venous access. Intermittently they require urgent intravenous administration of fluids and medication.

Objective: To analyze the use of implanted port-a-caths in children with medical complexity who have neurologic impairment and difficult venous access.

Materials And Methods: We performed a single-center observational study of port-a-caths placed by interventional radiologists in children with medical complexity with neurologic impairment. We analyzed peripheral intravenous access attempts, peripheral intravenous starts, peripheral intravenous complications, alternative temporary central venous access devices, port-a-cath insertions, catheter days, access days, port-a-cath-related complications, hospital admissions and emergency department visits. We compared the year pre port-a-cath to the year post port-a-cath.

Results: Twenty-one children with medical complexity with neurologic impairment (10 boys, 11 girls; median age 4.1 years; median weight 13.7 kg) underwent 26 port-a-cath insertions (median catheter days 787). In the year post port-a-cath compared to pre port-a-cath there was a highly significant reduction (P<0.001) in numbers of peripheral intravenous attempts, peripheral intravenous starts and skin punctures; and a significant reduction (P<0.05) in need for other devices, number of emergency department visits, emergency department visits resulting in hospital admissions, and total admissions. Adverse events were graded as mild (n=18), moderate (n=6) and severe (n=0).

Conclusion: Port-a-cath placement in children with medical complexity with neurologic impairment significantly reduced all peripheral intravenous attempts, peripheral intravenous starts, skin punctures, total number of emergency department visits, visits culminating in admission, and total number of inpatient admissions. Advantages must be considered against potential port-a-cath-related adverse events.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00247-019-04470-wDOI Listing
September 2019

Quantitative color-coded digital subtraction neuroangiography for pediatric arteriovenous shunting lesions.

Childs Nerv Syst 2019 12 6;35(12):2399-2403. Epub 2019 Jul 6.

Image Guided Therapy, Department of Diagnostic Imaging, Department of Medical Imaging, Hospital for Sick Children, University of Toronto, 555 University Ave, Toronto, ON, M5S, Canada.

Background: Several complex pediatric neurovascular conditions are amenable to endovascular treatment. Given the unique anatomical and physiological challenges in children, there is an ongoing need for tools and techniques that provide accurate information for treatment planning, while minimizing exposure to ionizing radiation and contrast. This is more so for neonates and infants with high-flow arteriovenous (AV) shunts that are challenging to assess using conventional techniques.

Objective: In this brief report, we describe, through representative cases, the potential role of quantitative color-coded digital subtraction angiography (qDSA) in neuroendovascular procedures in children with high-flow AV shunting lesions.

Methods: Images were obtained using an ArtisQ biplane system (Siemens Healthineers, Erlangen, Germany). Post-processing was performed at a dedicated workstation (Syngo, Siemens) using the iFlow module to generate color-coded maps of individual digital subtraction angiography runs.

Conclusion: Color-coded qDSA provides real-time quantitative information in high-flow AV shunting neurovascular lesions. This can potentially help direct treatment choices, optimize endovascular treatment protocols, monitor outcomes, and determine treatment end points.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00381-019-04289-8DOI Listing
December 2019

Reliability and safety of Etomidate speech test in children with drug resistant focal epilepsy.

Epilepsy Res 2019 10 10;156:106150. Epub 2019 Jun 10.

Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, M5G1X8, Canada. Electronic address:

Purpose: To review our experience with the Etomidate speech test (EST) for lateralizing language in children undergoing epilepsy surgery evaluation METHODS: This retrospective study included children (<18 years) with drug refractory focal epilepsy undergoing EST for bilateral or poorly reliable language representation on functional MRI. Data for consecutive children who underwent EST between January 2013 to June 2017 were reviewed.

Results: Twenty-one children (mean age at EST, 13.1 ± 4.4 years) were studied, with 19-right hemispheric and 20 left hemispheric injections. Six patients had neurological co-morbidities. Duration of ipsilateral EEG slowing was sufficient for speech testing in all children with a single bolus of Etomidate per carotid artery. Language was lateralized to one hemisphere in 17 (80.9%) and bilateral in two cases. EST was unsuccessful in two patients because of diffuse EEG slowing. Contralateral transient frontal EEG slowing was seen in 14 (73.7%) cases. EST was well tolerated in all the patients.

Conclusions: The EST was found to be successful and safe in lateralizing language in most of our drug refractory pediatric epilepsy cohort.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.eplepsyres.2019.106150DOI Listing
October 2019

Unruptured intracranial aneurysms in children: 18 years' experience in a tertiary care pediatric institution.

J Neurosurg Pediatr 2019 May 24;24(2):184-189. Epub 2019 May 24.

1Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Ontario.

Objective: There are little data in the literature on the characteristics and natural history of unruptured intracranial aneurysms in children. The authors analyzed their experience with unruptured intracranial aneurysms in the pediatric population at their tertiary care pediatric institution over the last 18 years. The first objective was to assess the imaging characteristics and natural history of these aneurysms in order to help guide management strategies in the future. A second objective was to evaluate the frequency of an underlying condition when an incidental intracranial aneurysm was detected in a child.

Methods: The authors conducted a Research Ethics Board-approved retrospective review of incidental intracranial aneurysms in patients younger than 18 years of age who had been treated at their institution in the period from 1998 to 2016. Clinical (age, sex, syndrome) and radiological (aneurysm location, type, size, thrombus, mass effect) data were recorded. Follow-up imaging was assessed for temporal changes.

Results: Sixty intracranial aneurysms occurred in 51 patients (36 males, 15 females) with a mean age of 10.5 ± 0.5 years (range 9 months-17 years). Forty-five patients (88.2%) had a single aneurysm, while 2 and 3 aneurysms were found in 3 patients each (5.8%). Syndromic association was found in 22 patients (43.1%), most frequently sickle cell disease (10/22 [45.5%]). Aneurysms were saccular in 43 cases (71.7%; mean size 5.0 ± 5.7 mm) and fusiform in the remaining 17 (28.3%; mean size 6.5 ± 2.7 mm). Thirty-one aneurysms (51.7%) arose from the internal carotid artery (right/left 1.4), most commonly in the cavernous segment (10/31 [32.3%]). Mean size change over the entire follow-up of 109 patient-years was a decrease of 0.6 ± 4.2 mm (range -30.0 to +4.0 mm, rate -0.12 ± 9.9 mm/yr). Interval growth (2.0 ± 1.0 mm) was seen in 8 aneurysms (13.3%; 4 saccular, 4 fusiform). An interval decrease in size (8.3 ± 10.7 mm) was seen in 6 aneurysms (10%). There was an inverse relationship between aneurysm size and growth rate (r = -0.82, p < 0.00001). One aneurysm was treated endovascularly with internal carotid artery sacrifice.

Conclusions: Unruptured pediatric intracranial aneurysms are most frequently single but can occur in multiples in a syndromic setting. None of the cases from the study period showed clinical or imaging signs of rupture. Growth over time, although unusual and slow, can occur in a proportion of these patients, who should be identified for short-term imaging surveillance.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3171/2019.4.PEDS18703DOI Listing
May 2019

Anatomical Venous Variants in Children With Cerebral Sinovenous Thrombosis.

Stroke 2018 Dec 3:STROKEAHA118023482. Epub 2018 Dec 3.

From the Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada (E.K., D.L.M., G.d., N.D., M.M.).

Background and Purpose- Literature is sparse on the frequency and significance of anatomical venous variants (AVVs) in pediatric cerebral sinovenous thrombosis (CSVT). Methods- We retrospectively reviewed children with CSVT and controls undergoing computed tomography/magnetic resonance venography from January 2008 to 2014. Clinical features examined included raised intracranial pressure, risk factors, and treatment. Radiological features examined included CSVT location, presence and type of AVVs, hemorrhagic venous infarction, and venous collateralization. Clinical outcome was measured by the pediatric stroke outcome measure and radiological outcome by thrombus recanalization. Results- Fifty-one children with CSVT were identified. Twenty-two (43%) had AVVs at presentation. Nineteen (86%) had hypoplasia/absence of major dural sinus, 5 (23%) had persistent fetal structures, 3 (14%) had duplications/fenestrations, and 1 (5%) had disconnected superficial and deep venous systems. Controls had a slightly higher but nonsignificant prevalence 26 (51%) of AVVs. No significant clinical and radiological differences were observed between children with CSVT and AVVs compared with those with typical venous anatomy. Conclusions- AVVs are seen in many children with and without CSVT and do not seem to alter the presentation or clinical course. The influence of these variations on the brain's ability to tolerate venous congestion because of thrombosis merits further study.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/STROKEAHA.118.023482DOI Listing
December 2018

Childhood Moyamoya: Looking Back to the Future.

Pediatr Neurol 2019 02 15;91:11-19. Epub 2018 Oct 15.

Department of Neurology, University of Washington, Seattle, Washington.

Moyamoya is a chronic, progressive steno-occlusive arteriopathy that typically affects the anterior circulation arteries of the circle of Willis. A network of deep thalamoperforating and lenticulostriate collaterals develop to by-pass the occlusion giving rise to the characteristic angiographic "puff of smoke" appearance. Moyamoya confers a lifelong risk of stroke and neurological demise, with peak age of presentation in childhood ranging between five and 10 years. Moyamoya disease refers to patients who do not have a comorbid condition, whereas moyamoya syndrome refers to patients in whom moyamoya occurs in association with an acquired or inherited disorder such as sickle cell disease, neurofibromatosis type-1 or trisomy 21. The incidence of moyamoya disease and moyamoya syndrome demonstrates geographic and ethnic variation, with a predominance of moyamoya disease in East-Asian populations. Antiplatelet therapy and surgical revascularization procedures are the mainstay of management, as there are no available treatments to slow the progression of the arteriopathy. Future research is required to address the major gaps that remain in our understanding of the pathologic basis, optimal timing for surgery, and determinants of outcome in this high-stroke risk condition of childhood.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.pediatrneurol.2018.10.006DOI Listing
February 2019

Arterial Wall Imaging in Pediatric Stroke.

Stroke 2018 04 16;49(4):891-898. Epub 2018 Mar 16.

From the Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, ON (N.D., I.Y., M.S., R.A., D.M., G.d.V., M.M.); Division of Neuroradiology, Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON (P.M., M.S.); Department of Diagnostic Imaging, Toronto Western Hospital, ON (D.M.); and Division of Neurology, Lucile Packard Children's Hospital Stanford, CA (J.E.).

Background And Purpose: Arteriopathy is common in childhood arterial ischemic stroke (AIS) and predicts stroke recurrence. Currently available vascular imaging techniques mainly image the arterial lumen rather than the vessel wall and have a limited ability to differentiate among common arteriopathies. We aimed to investigate the value of a magnetic resonance imaging-based technique, namely noninvasive arterial wall imaging (AWI), for distinguishing among arteriopathy subtypes in a consecutive cohort of children presenting with AIS.

Methods: Children with confirmed AIS and magnetic resonance angiography underwent 3-Tesla AWI including T1-weighted 2-dimensional fluid-attenuated inversion recovery fast spin echo sequences pre- and post-gadolinium contrast. AWI characteristics, including wall enhancement, wall thickening, and luminal stenosis, were documented for all.

Results: Twenty-six children with AIS had AWI. Of these, 9 (35%) had AWI enhancement. AWI enhancement was associated with anterior circulation magnetic resonance angiography abnormality and cortical infarction in 8 of 9 (89%) children and normal magnetic resonance angiography with posterior circulation subcortical infarction in 1 (1 of 9; 11%) child. AWI enhancement was not seen in 17 (65%), 10 (59%) of whom had an abnormal magnetic resonance angiography. Distinct patterns of pre- and postcontrast signal abnormality were demonstrated in the vessel wall in the region of interest in children with transient cerebral arteriopathy, arterial dissection, primary central nervous system angiitis, dissecting aneurysm, and cardioembolic stroke.

Conclusions: AWI is a noninvasive, high-resolution magnetic resonance AWI technique, which can be successfully used in children presenting with AIS. Patterns of AWI enhancement are recognizable and associated with specific AIS pathogeneses. Further studies are required to assess the additional diagnostic utility of AWI over routine vascular imaging techniques, in childhood AIS.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/STROKEAHA.117.019827DOI Listing
April 2018

Imaging Features of Common Pediatric Intracranial Tumours: A Primer for the Radiology Trainee.

Can Assoc Radiol J 2018 Feb 22;69(1):105-117. Epub 2017 Dec 22.

Division of Neuroradiology, Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.carj.2017.10.006DOI Listing
February 2018

Intracranial artery to artery spontaneous revascularization in a child.

Childs Nerv Syst 2017 Nov 4;33(11):2035-2038. Epub 2017 Jul 4.

Pediatric Neuroradiology, Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON, M5G 1H4, Canada.

Introduction: Intracranial artery-to-artery antegrade revascularization is a poorly recognized entity, more so when it involves main stem arteries. The etiology, appearance, and significance of this condition are not described in the literature.

Case Presentation: We describe a case of spontaneous revascularization of a chronically occluded middle cerebral arterial branch by collaterals from the proximal segment reconstituting distal flow, mimicking a brain arteriovenous malformation in a 9-year old boy. We discuss the nature of these channels, presumed to be related to artery to artery collaterals that are either dilated adventitial vasa vasorum, or, more likely, leptomeningeal collaterals that are hypertrophied in response to cerebral demand. We review the literature regarding intracerebral vasa vasorum and leptomeningeal collaterals including their imaging.

Conclusion: Recognizing the tortuous channels associated with this type of vascular abnormality as normal vessels reconsituting distal flow may prevent unnecessary and potentially dangerous treatments.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00381-017-3498-7DOI Listing
November 2017

Splanchnic, Thoracoabdominal, and Cerebral Blood Flow Volumes in Healthy Children and Young Adults in Fasting and Postprandial States: Determining Reference Ranges by Using Phase-Contrast MR Imaging.

Radiology 2017 10 22;285(1):231-241. Epub 2017 May 22.

From the Department of Diagnostic Imaging (P.M., S.J.Y., N.T., J.W., D.S., M.P., P.C.D., M.S., L.G.W., G.B.C.), Division of Cardiology, Department of Pediatrics (S.J.Y., R.C., J.W., D.S., M.P., M.S., L.G.W.), and Division of Gastroenterology, Hepatology, and Nutrition (S.C.L.), the Hospital For Sick Children, 555 University Ave, Toronto, ON, Canada M5G 1X8; and Departments of Medical Imaging (P.M., S.J.Y., P.C.D., M.S., L.G.W., G.B.C.), and Pediatrics (R.C., S.C.L.), University of Toronto, Toronto, Canada.

Purpose To estimate reference ranges for blood flow volume (BFV) in major splanchnic, thoracoabdominal, and neck vessels by using phase-contrast magnetic resonance (MR) imaging in children and young adults in fasting and postprandial states. Materials and Methods In this institutional research ethics board-approved prospective study, healthy volunteers underwent phase-contrast MR imaging in a fasting state and again after a standardized meal. BFV values were reported as medians and ranges, and postmeal to premeal BFV ratios were calculated. BFVs in volunteers divided into two groups according to age (≤18 years old and >18 years old) were compared by using the Mann-Whitney test adjusted for multiple comparisons. Linear regression for internal validation of BFV and Pearson correlation and Bland-Altman analysis for interobserver agreement were used. Results Reference ranges for BFVs were estimated in 39 volunteers (23 male and 16 female; mean age, 21.2 years ± 8.5; range, 9-40 years) and were indexed according to body surface area, with internal validation (R = 0.84-0.92) and excellent interobserver agreement (R = 0.9928). There was an almost 30% increase in total abdominal BFV (P < .0001) in response to a meal, which was the result of a threefold increase in superior mesenteric artery BFV (P < .0001). BFV after the meal remained unaffected in the celiac artery and cerebral circulation. Significantly higher normalized BFVs in the cerebral circulation were measured in children with both preprandial (P = .039) and postprandial (P = .008) status than those in adults. Conclusion Reference ranges for BFVs and changes in BFVs in response to a meal in major splanchnic, thoracoabdominal, and neck vessels were estimated by using phase-contrast MR imaging in healthy volunteers to allow hemodynamic assessment of children and young adults with various diseases. RSNA, 2017 Online supplemental material is available for this article.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1148/radiol.2017162114DOI Listing
October 2017

MRI of thoracic outlet syndrome in children.

Pediatr Radiol 2017 Sep 10;47(10):1222-1234. Epub 2017 May 10.

Division of Plastic Surgery, Department of Pediatric Surgery, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada.

Thoracic outlet syndrome is caused by compression of the neurovascular bundle as it passes from the upper thorax to the axilla. The neurovascular bundle can be compressed by bony structures such as the first rib, cervical ribs or bone tubercles, or from soft-tissue abnormalities like a fibrous band, muscle hypertrophy or space-occupying lesion. Thoracic outlet syndrome commonly affects young adults but can be seen in the pediatric age group, especially in older children. Diagnosis is based on a holistic approach encompassing clinical features, physical examination findings including those triggered by various maneuvers, electromyography, nerve conduction studies and imaging. Imaging is performed to confirm the diagnosis, exclude mimics and classify thoracic outlet syndrome into neurogenic, arterial, venous or mixed causes. MRI and MR angiography are useful in this process. A complete MRI examination for suspected thoracic outlet syndrome should include the assessment of anatomy and any abnormalities using routine sequences, vessel assessment with the arms in adduction by MR angiography and assessment of dynamic compression of vessels with abduction of the arms. The purpose of this paper is to describe the anatomy of the thoracic outlet, causes of thoracic outlet syndrome, the MR imaging techniques used in its diagnosis and the principles of image interpretation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00247-017-3854-5DOI Listing
September 2017

Measuring hemoglobin prior to early discharge without routine surveillance ultrasound after percutaneous native renal biopsy in children.

Pediatr Nephrol 2017 10 5;32(10):1927-1934. Epub 2017 May 5.

Image Guided Therapy, Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, ON, M5G 1H4, Canada.

Background: We aimed to evaluate the role of post-procedural hemoglobin (hb), without pre-discharge ultrasound (US), after US-guided renal biopsy in children.

Methods: A retrospective review was conducted of consecutive outpatient native kidney biopsies over an 8-year period. Procedures were performed under real-time US guidance. Data collected included number of passes, presence and size of perinephric hematoma, age, body mass index (BMI), blood pressure (BP), fasting status, hb and platelets. Continuous variables were expressed as mean ± standard deviation, group differences were tested with Student's unpaired t test and analysis of variance and correlations were assessed using Pearson's r. Significance was defined as p < 0.05. Hb changes (g/L), percentage hb (%hb) change, hematoma size and positive and negative predictive values (PPV, NPV, respectively) were analyzed.

Results: A total of 330 procedures in 300 children (141 females, mean age 11.2 ± 4.30 years) were analyzed. Post-procedural hematoma occurred in 63%. There was a significant (p = 0.0001) post-procedural hb decrease of 6.3 ± 5.5 g/L and %hb decrease of 4.56 ± 4.01%. Fasting during pre-procedural hb estimation and procedural hematoma was associated with a greater hb drop. A ≥10% hb drop had 73% PPV for repeat blood work and US and a 17% PPV for admission, whereas a <10% hb drop had a NPV of 84% and 98%, respectively. Hb change showed a weak correlation with age, and hematoma size showed a weak inverse correlation with platelet count, but no correlation with BMI, number of passes or BP.

Conclusions: Bleeding complications from US-guided native kidney biopsies in pediatric outpatients can be safely followed by a complete blood count at 6 h post procedure. A 10% hb decrease is strongly associated with requirement for further testing and/or admission.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00467-017-3680-xDOI Listing
October 2017

Hallway Conversations in Physics.

AJR Am J Roentgenol 2017 07 12;209(1):W44-W46. Epub 2017 Apr 12.

1 The Hospital for Sick Children Toronto, ON, Canada

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2214/AJR.17.18064DOI Listing
July 2017