Twenty-seven of 1,018 children evaluated with contrast material-enhanced computed tomography (CT) after blunt trauma demonstrated a characteristic hypoperfusion complex. This complex was usually seen in young children (median age, 2 years). CT findings in all 27 patients included a dilated, fluid-filled bowel and abnormally intense enhancement of the bowel wall, mesentery, kidneys, aorta, and inferior vena cava. Twenty-four percent of all children with a Trauma Score of 10 or less and 20% with a Glasgow Coma Score of 6 or less had the hypoperfusion complex. All 27 patients had a normal blood pressure immediately before CT, but five (19%) became hypotensive within 10 minutes of intravenous contrast material administration. Twenty-three children (85%) died. Of 16 children who survived 24 hours, four (25%) developed renal insufficiency. The intense multiorgan enhancement pattern seen in the hypoperfusion complex indicates tenuous hemodynamic stability. Recognition that the constellation of CT findings is due to hypovolemic shock and not to injured viscera helps avoid unnecessary laparotomy.

Persistent fifth aortic arch is a rare anomaly, with only 22 cases reported.1,2 Its recognition and successful management when associated with coarctation is even rarer. We present a child with persistent left fifth aortic arch and complex coarctation successfully diagnosed and repaired.

CT of blunt abdominal trauma in childrenGA Taylor, CJ Guion, BM Potter and MR EichelbergerAudio Available | Share

Since 1981, we have evaluated and treated 22 children with renovascular hypertension (RVH). Seventeen patients had stenosis of their native renal arteries, and five had stenosis of the artery in a transplanted kidney. RVH was caused by fibromuscular dysplasia in 13 patients, by trauma in 2 patients, and by arteritis in 2 patients. Among the patients who had transplanted kidneys, three had technical causes for stenosis and two had stenosis due to rejection. The disease was unilateral in 10 patients, bilateral in 5, and present in a solitary kidney in 7, including the five renal transplants. Diagnostic studies that strongly suggested the presence of renovascular disease were an initial diastolic blood pressure greater than 100 mm Hg, an elevated peripheral vein renin activity level, and an abnormal renal scan if the patient's hypertension was being controlled with an angiotensin-converting enzyme inhibitor (ACEI). Only the renal arteriogram was 100% accurate in confirming the presence of RVH. Percutaneous angiographic correction was attempted in 13 patients and resulted in lasting improvement of the hypertension in five (38%). Surgical revascularization was attempted in 17 children, including the 8 with failed angioplasty, with improvement or cure of the hypertension in 15 patients (88%). Combining percutaneous transluminal angioplasty (PTA) and surgical results gave 20 of 22 patients (91%) with cure or improvement of their hypertension. Four of 27 affected kidneys (15%) could not be revascularized and were removed. We conclude from this series of patients that despite improvements in noninvasive studies, renal arteriogram remains the only study that is 100% accurate in evaluating children for RVH.(ABSTRACT TRUNCATED AT 250 WORDS)

This study was performed in order to test the hypothesis that abdominal computed tomography (CT) can assist in the decision to perform laparotomy in children following blunt trauma to the abdomen. Three hundred forty children with blunt abdominal trauma underwent evaluation with CT. Abdominal injuries were detected in 84 children (25%). These included: 75 injuries to solid viscera in 60 patients (30 splenic, 29 hepatic, 13 renal, and three pancreatic); four injuries to hollow viscera (three small bowel transections, and one rupture of the urinary bladder); and 23 skeletal injuries (21 fractures of the pelvis, and two lumbar spine subluxations). Injury to solid viscera was categorized as minor in 32 (43%), moderate in 18 (24%), or severe in 25 (33%) according to an assessment of the percentage of parenchyma involved. Hemoperitoneum was detected in 42 patients, and characterized as small in 18 (43%), moderate in nine (21%), and large in 15 (36%). CT was useful in establishing the location and extent of injuries, and in detecting the presence of blood or air in the peritoneal cavity. However, the extent of injury to solid viscera detected on CT did not correlate with the need for laparotomy. Of 46 moderate to severe anatomic injuries of the liver, spleen or kidney, only five (9%) required surgical intervention because of persistent bleeding or infection. Although laparotomy occurred more frequently in the presence of a large hemoperitoneum, only 6/24 (25%) with moderate to large hemoperitoneum required surgical exploration. This analysis confirms the usefulness of CT for detection of location and extent of injury in pediatric blunt abdominal trauma.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical and radiographic records of 274 children who were examined with abdominal computed tomography (CT) after blunt abdominal trauma were retrospectively evaluated to test the hypothesis that CT can assist in decisions to perform laparotomy in children with hepatic or splenic injury. CT demonstrated parenchymal injuries in 36 patients (13%) or 20 livers and 21 spleens. Injury to these organs was categorized as minor (39%), moderate (39%), and severe (21%) according to an assessment of the percentage of parenchymal involvement. Hemoperitoneum was detected in 27 of 36 patients (75%). One of 13 (4.7%) with a moderate to large splenic injury underwent splenorrhaphy because of persistent bleeding. One of 12 (5%) with a moderate to large hepatic injury required late operative intervention due to a large necrotic segment. Both children had a large amount of peritoneal fluid. Two of 16 patients (13%) with moderate to large hemoperitoneum required surgery for liver or splenic injury. The decision for laparotomy should not be based on the extent of injury as shown at CT but on the physiologic condition of the child.

We evaluated the physical characteristics and contrast-dose-detail performance of 11 rare-earth and three calcium tungstate screen-film systems. Measurements included system speed, contrast, sensitometry, RMS noise, square-wave response function, and contrast-dose-detail analysis. The major differences in physical characteristics among systems were system speed and RMS noise. Square-wave response differences were more subtle. For contrast-dose-detail analysis, the rare-earth screen-film systems and the calcium tungstate system responses were significant over a limited subject contrast range as a function of detail diameter. Relative dose efficiency in the noise-limited region is a function of the properties of the screen only and is independent of the film.

Diagnostic accuracy was evaluated in a signal detection experiment that used low-contrast acute lesions in a living dog model. At the high levels of certainty normally used by radiologists, rare earth screen-film systems provided accuracy comparable to that of a reference calcium tungstate screen-film system. Additionally subjective image quality evaluation for a given imaging task (clinical pediatric anterior-posterior chest films) based on visualization of anatomic landmarks and physical parameters has been conducted for several rare earth and one calcium tungstate screen-film system. The correspondence of subjective physical ranking with physical and psychophysical measurements was investigated. Evaluating the visualization of anatomic parameters can provide a clear and objective distinction among systems with comparable physical and psychophysical properties.

Patients with end-stage renal disease who develop hypersplenism, patients with mild neutropenia, and those patients whose WBC fails to increase in response to cortisol administration will develop significant neutropenia following transplantation with routine doses of azathioprine. This "intolerance" of azathioprine mandates a reduction in the dose of azathioprine often resulting in allograft rejection. Splenectomy will prevent azathioprine-induced neutropenia, but the hazards of splenectomy in these immunosuppressed patients have led to attempts to salvage at least part of the spleen. Partial splenic ablation by embolization has been utilized in adults prior to transplantation to prevent azathioprine-induced neutropenia while preserving the spleen's protective mechanisms against infection. Eight children in our series of transplant candidates required a reduction of splenic function to prevent azathioprine induced neutropenia. One child had a functioning renal allograft but had recurrent neutropenia limiting the azathioprine dose. Partial splenic embolization was attempted in four children and was initially successful in two. Both patients later developed recurrent neutropenia and needed partial splenectomy. The two patients in whom partial splenic embolization was unsuccessful and five further patients in whom embolization was not attempted also underwent partial splenectomy. Approximately 75% to 80% of the spleen was resected. Six children have since undergone renal transplantation and one child had a transplant with chronic rejection at the time of partial splenectomy. Routine doses of azathioprine have been used in these children with no episodes of neutropenia or sepsis observed. We recommend partial splenectomy in those children requiring renal transplantation who are at risk for development of azathioprine induced neutropenia.

The use of percutaneous transluminal angioplasty as the primary treatment of renovascular stenosis in adults has recently been described. Previously, only three children have been reported to have undergone transluminal angioplasty for stenosis of the renal artery and hypertension. At our hospital, transluminal angioplasty was attempted in four children with renal artery stenosis; one attempt was successful and three were unsuccessful. The three patients who required surgical repair of the renal artery after unsuccessful transluminal angioplasty have been described in detail. The histopathology of the stenotic vessels is also discussed. Based on the analysis of the three children, certain criteria have been derived to select pediatric patients with renovascular hypertension either for attempted transluminal angioplasty or for primary surgical revascularization.

Balloon atrial septostomy is an accepted method for palliation of certain types of congenital heart disease. However, malposition of the balloon may lead to cardiac perforation, avulsion of an atrioventricular valve, or laceration of the systemic or pulmonary veins. Inasmuch as single-phase fluoroscopy may not identify balloon position correctly and as biplane fluoroscopy adds significant radiation exposure, two-dimensional echocardiography has been used to assist in balloon atrial septostomy in ten infants. The catheter is advanced from the inferior vena cava to the right atrium across the foramen ovale to the left atrium with the echo transducer in the subxiphoid position. The balloon is inflated and its position within the left atrium is confirmed by echo. The catheter is withdrawn according to the technique of Rashkind. Withdrawal is halted when the balloon traverses the atrial septum. Adequate septostomy is indicated on echo by a defect at least 5 mm in diameter and by flapping of the inferior rim of the atrial septum. There were no complications using this technique and a clinically adequate septostomy was achieved in each patient. Two-dimensional echocardiography-assisted balloon atrial septostomy minimizes risk of complications and decreases exposure to ionizing radiation.