Arnold Shkolnik

Clinical application of ultrasonography in the diagnosis of intussusception

Sixty-five consecutive patients seen in a pediatric emergency department, in whom the diagnosis of intussusception was considered, had an ultrasound examination of the abdomen before a barium enema. The mean age of the patients was 1.7 years (range 2 weeks to 5 years). Intussusception was detected by ultrasonography in all 20 cases proved by barium enema. There were three false-positive ultrasound results (sensitivity = 100%, confidence interval (Cl) = 86% to 100%; specificity = 93%, Cl = 86% to 96%). Normal findings on ultrasonography correlated with a negative barium enema results in 42 of 42 cases (negative predictive value = 100%, Cl = 94% to 100%). No intussusception was missed by ultrasonography. To determine which patients would most benefit from ultrasonography, we divided patients into either a high-risk group (81% with intussusception) or a low-risk group (14% with intussusception) on the basis of clinical symptoms (p less than 0.01). If each high-risk child had a barium enema and each low-risk child had an ultrasound study as their initial diagnostic test, 89% of the patients in this study would have undergone only one examination. We conclude that ultrasonography can be used as a rapid, sensitive screening procedure in the diagnosis or exclusion of childhood intussusception. Children considered at low risk of having intussusception on the basis of clinical symptoms should initially have an ultrasound examination; patients at high risk should have an immediate barium enema.

Neonatal aortic thrombosis: Recent experience

To evaluate the course, use of diagnostic modalities, management, and outcome of aortic thrombosis associated with umbilical artery catheterization, we reviewed 20 cases of aortic thrombosis diagnosed by ultrasonography (n = 16) or aortography (n = 4) over 4 years. Fourteen of 20 infants had severe perinatal asphyxia, suggesting that asphyxia predisposes to aortic thrombosis. Ultrasonography provided information about the size, location, and configuration of the thrombus and was useful in following thrombus size with therapy. Radionuclide renography-scintigraphy demonstrated abnormal renal function in all 11 patients scanned. Six patients with minor thrombosis (hypertension as the only sign) improved without specific therapy. Nine infants had moderate thrombosis (multiple signs but normal urine output); all survived with a variety of therapies; two were not given anticoagulant or fibrinolytic agents; three improved with heparin alone; and one had surgery without recurrence of the thrombus. Resolution of moderate thrombosis followed streptokinase therapy in two of three infants. All five babies with anuria from major thrombosis died. Hepatic infarction associated with aortic thrombosis was found in three of three autopsies.

Genetic amniocentesis in twin gestations

Among 1,613 women studied with routine ultrasonography prior to genetic amniocentesis at Northwestern University Medical School, 25 of 26 multiple gestations were detected. Sampling of fluid from both amniotic sacs was requested by 20 women with twin gestations in which both fetuses were ultrasonographically determined to be viable and of normal size. Fluid was obtained successfully from both amniotic sacs in 19 of 20 cases. The conclusions are that (1) twin gestations can be reliably detected by the use of routine ultrasonography, (2) both amniotic sacs can usually be sampled, and (3) the complication rate appears to be minimal to the patient and the fetuses, although the sample size is still small.

Fetal cranial and craniocervical masses: Ultrasound characteristics and differential diagnosis

Ultrasound is assuming an essential role in the detection of fetal cranial and spinal anomalies. Illustrated in this article is the sonographic appearance of cranial abnormalities wherein the diagnosis of encephalocele is clear cut because the anatomic defect of the neural tube is visualized. Additionally presented is a variety of cranial and craniocervical cystic masses, including meningocele, wherein the anatomic defect of the neural tube is not apparent and the diagnosis is reached by careful attention to the specific ultrasonic characteristics of each mass.

Favorable outcome of neonatal aortic thrombosis and renovascular hypertension

Fifteen children with renovascular hypertension as a result of aortic thrombosis were followed for a mean of 26 months (range 5 to 58 months) to determine outcome. As neonates, all patients had hypertension and elevated plasma renin activity. Of 11 patients studied with radionuclide renography and scintigraphy, 10 had abnormal renal blood flow; three had complete absence of unilateral perfusion. On follow-up examination all children were normotensive; five children ages 5 to 24 months required antihypertensive medication. Of 15 children, 14 had normal statural growth; all had normal serum creatinine, plasma renin activity, and calculated glomerular filtration rate values. Patients with complete absence of renal perfusion unilaterally remained functionally anephric; children with less severe perfusion deficits had improved perfusion as shown by radionuclide renography and scintigraphy. We believe that many patients with aortic thrombosis and renovascular hypertension who have had aggressive antihypertensive therapy in the neonatal period will have good renal function and increased perfusion to the affected kidney 2 years later.

Ultrasonography and diagnosis of pediatric genitourinary rhabdomyosarcoma

Rhabdomyosarcoma is the most common tumor of the lower genitourinary tract in children during their first two decades of life. Four patients with genitourinary rhabdomyosarcoma are presented, with ultrasonographic and radiographic findings. The utility of ultrasound in the diagnosis of this pediatric tumor is emphasized.

Ultrasound prior to amniocentesis for genetic counseling

Ultrasonic placental and fetal head localization, although not mandatory, may minimize the risks of amniocentesis for use in genetic counseling. It permits choosing a site other than low midline with a low-lying anterior placenta; with a posterior placenta, the insertion within the amniotic cavity should stop short of the placenta. Although complications of amniocentesis in the second trimester without ultrasound have been very few, it seems worthwhile to try to decrease even this small risk by the use of ultrasound.

Five-Year-Old Female with a Cyst of the Fourth Ventricle

Robin Bowman: This is a 5-year-old female with a history of hydrocephalus secondary to aqueductal stenosis. She has a ventriculoperitoneal shunt and has had approximately 4 revisions, the last one in 1993. She now presents with a 2-month history of intermittent headaches and nausea. She had an MRI which was reported to show a fourth ventricular cyst. She has had no change in vision, no fever or upper respiratory infection and no seizures. She takes Tylenol every time she has a headache. She has a history of prior surgery with no difficulty with anesthesia. She has no known allergies. She takes no medications, except Tylenol on a p.r.n. basis. Her past medical history is significant for a small atretic encephalocele removed from the midparietal vertex at birth. On physical examination, her skin was without rashes. She had no perivalvular fluid collection around the shunt. Her extraocular eye movements were full. Her pupils were equal and reactive to light. Ear, nose and throat examination revealed no lanimaria, positive enlarged tonsils, but no exudate was noted. Her neck was supple with no palpable nodes. Her back and thorax were negative for scoliosis. Her heart showed a normal sinus rhythm; S1–S2 was auscultated and no murmurs were appreciated. Her lungs were clear to auscultation bilaterally. Her abdomen was soft and nontender. Her extremities were without edema. Her neurological examination revealed her to be alert and oriented !3, playful and smiling. Her face was symmetric. She was moving all four extremities with 5/5 motor strength throughout. She had 2+ deep tendon reflexes in the upper extremities bilaterally and 1+ in the lower extremities bilaterally. She had a negative Babinski sign. She had an intact sensory reaction to light touch and proprioception. Preoperative laboratory tests: type, cross and CBC; white blood cells: 4.9 thou/Ìl; red blood cells: 4.96 mil/Ìl; hemoglobin: 13.5 g/dl; hematocrit: 34.7%; MCV: 81 fl; MCH: 27.2 pg; MCHC: 33.6 mean %; RBC dist and width: 14.1%; platelets: 344 thou/Ìl; mean platelet volume: 7.1 fl. She was taken to the operating room for a craniotomy.

1547 NEWER DIAGNOSTIC MODALITIES AND THERAPY FOR NEONATAL AORTIC THROMBOSIS

Although aortic thrombosis is a recognized complication of umbilical artery catheterization, there is limited experience with newer imaging modalities and therapy. Between 1981 and 1984, 16 neonates developed aortic thrombosis by ultrasonographic (15/16) and/or aortographic (2/16) criteria. Of the 16, 10 were full term, 11 were severely asphyxiated and 8 had persistent pulmonary hypertension. The duration of UAC was 9.5 ± 5.3 (SD) days. The clinical presentation varied from hypertension to multiorgan failure. Ultrasound examination of the aorta was helpful in estimating the size and location of the thrombus and in assessing response to therapy. Radionuclide renography demonstrated abnormal renal function in 9 of 9 studies; on follow-up the renal lesions were persistent (4/4). Five mildly symptomatic patients improved without specific therapy. Of six moderately symptomatic thrombi, 3 improved with heparin, 1 was removed surgically and 2 resolved in 6-7 days with streptokinase. All 5 babies with large aortic thrombi and multiorgan failure died despite therapy including heparin, urokinase, streptokinase and surgery. We conclude that diagnosis by ultrasound and radionuclide renography are important for prompt institution of therapy. In carefully selected cases fibrinolytic therapy may result in rapid complete thrombus resolution.