Birgit Zieger

Reduction in voiding cystourethrographies after the introduction of contrast enhanced sonographic reflux diagnosis.

Abstract.Background: Voiding urosonography (VUS) using the intravesical application of an US contrast medium (Levovist) has been shown to have very high sensitivity and specificity in the diagnosis of vesicoureteric reflux (VUR) compared to voiding cystourethrography (VCUG). Objective: To determine the extent of reduction of VCUGs after adding VUS to the diagnostic algorithm of VUR. Materials and methods: Over 2 years, 449 children (162 boys, 287 girls) were referred for diagnosis of possible VUR. The selection of a particular reflux examination was based on pre-defined criteria. VUS was performed primarily in girls and follow-up cases. The indications for VCUG were as follows: (a) boys – first examination for VUR, (b) specific request for urethra or bladder imaging, (c) girls – when VUR was diagnosed in the VUS and no VCUG had been done previously, and (d) inadequate VUS. Results: VCUGs were primarily carried out in 141 cases. VUSs were performed in 308 patients. In 69 of these patients a VCUG followed during the same examination session. Thus 239 of 449 patients underwent only VUS, resulting in reduction of the VCUGs by 53 %. Conclusions: The number of VCUGs was significantly reduced as a result of the implementation of VUS as part of the routine diagnostic imaging modality for VUR. Consequently, the number of children that would have been exposed to ionising radiation was reduced by over half.

Diagnostik des vesikoureteralen Refluxes mit der echoverstärkten Miktionsurosonographie

ZusammenfassungEinleitung: Ziel der Arbeit war es, zu prüfen, ob die echoverstärkte Miktionsurosonographie (MUS) der Röntgen-Miktionszystourethrographie (MCU) in der Diagnostik des vesikoureteralen Refluxes (VUR) vergleichbar ist. Methodik: Eine echoverstärkte MUS und eine MCU wurden bei 114 Patienten nacheinander in der gleichen Sitzung zum Nachweis oder Ausschluß eines vesikoureteralen Refluxes (VUR) durchgeführt. Nach einer Sonographie des Harntrakts erfolgte die Füllung der Blase mit Kochsalzlösung und Levovist® (Schering AG, Berlin). Ein Reflux wurde diagnostiziert, wenn sich im Harnleiter oder Nierenbecken hyperechogene, flottierende Mikrobläschen darstellten. Ergebnisse: Es standen 226 Nieren-Harnleiter-Einheiten zur Analyse zur Verfügung. Ein Reflux wurde in 80 Einheiten diagnostiziert. Alle Refluxgrade kamen vor. In 15 Einheiten wurde in der MUS ein VUR diagnostiziert, aber nicht in der MCU. Das Gegenteil war in 3 Einheiten der Fall. Die echoverstärkte MUS hat damit im Vergleich zur Referenzmethode MCU eine hohe Sensitivität und Spezifität. Die lange Kontrastdauer von Levovist® ermöglicht überzeugende Bilder und eine hohe diagnostische Sicherheit. Schlußfolgerung: Die echoverstärkte MUS ist der MCU in der Diagnostik des VUR gleichwertig.SummaryAim: To ascertain the diagnostic efficacy of reflux sonography with the application of the echo-enhancing agent Levovist® in comparison with X-ray voiding cystourethrography (VCUG). Patients and methods: Echo-enhanced voiding urosonography (VUS) and VCUG were performed successively in one examination session in 114 children referred for the investigation of possible vesicoureteral reflux (VUR). After sonography of the urinary tract the bladder was filled with normal saline and Levovist® was administered. Reflux was diagnosed when hyperechogenic, floating microbubbles appeared in the ureters or renal pelvises. Results: A total of 226 kidney-ureter units were available for analysis. Reflux was diagnosed in 80 units. All grades of reflux were represented. In 15 kidney-ureter units VUR was diagnosed with echo-enhanced VUS but was not seen at VCUG. The contrary was true in 3 units. High sensitivity and specificity in comparison to the VCUG could be attributed to the echo-enhanced VUS. The long imaging window attainable with Levovist® makes the documentation of convincing images possible, contributing to the high diagnostic efficacy. Conclusion: Echo-enhanced VUS is comparable to VCUG in the diagnosis of reflux.

Sonomorphology and involution of the normal urachus in asymptomatic newborns.

Background. The number of reports on the sonomorphology of the urachus or urachal remnants in neonates and the pattern of involution is limited. Objective. To determine whether a sonographically visible urachus in the first months of life is a pathologic condition and whether postnatal involution can be demonstrated by ultrasound. Materials and methods. A total of 102 asymptomatic infants (premature and term newborns) were examined with a high-resolution 7.5-MHz linear transducer between 0 and 60 days of age. In 70 infants, a second examination followed 3–5 months later. Results. In all infants, the urachus could be identified on the first examination. Different morphological types were differentiated. There was no difference between premature and term newborns in the morphology of the urachus. Spontaneous involution of the urachus was observed in all infants receiving a second examination, and they most often showed a fusiform urachal remnant at the apex of the bladder. Conclusion. Involution of the urachus is not complete at birth and can be followed up sonographically in the first months of life. This knowledge should prompt a new strategy in young infants with a discharging umbilicus or even an infected urachus. Instead of early surgery, a conservative approach under sonographic control seems reasonable, because there is a chance of spontaneous involution and any abnormal development can be detected by ultrasound.

Bilateral renal venous thrombosis in a neonate associated with resistance to activated protein C

Abstract. Renal venous thrombosis (RVT) is a serious complication of neonates. In most cases the underlying cause of RVT remains unclear. Here we report a neonate with bilateral RVT and adrenal haemorrhage associated with a heterozygous mutation of the gene encoding for clotting factor V, resulting in resistance to activated protein C. Vigorous thrombolytic therapy with urokinase followed by recombinant tissue plasminogen activator dissolved the thrombus in the inferior vena cava and restored perfusion of both kidneys. However, a haemorrhagic rupture of the right kidney occurred, requiring emergency nephrectomy. Despite reperfusion of the left kidney and resumption of urine output, the patient remained dialysis dependent. Due to persistent adrenal insufficiency, long-term substitution of hydrocortisone was necessary. The patient was prophylactically treated with coumarin during the first 6 months of life and is now waiting for renal transplant at the age of 1 year.

Das Schädel-Hirn-Trauma des Kindes

ZusammenfassungDas diagnostische Vorgehen beim Schädel-Hirn-Trauma des Kindes wird in dieser Arbeit, in Anlehnung an den Heidelberger Konsensus zur Traumadiagnostik, dargestellt. Die Patienten sollten vor einer radiologischen Untersuchung in drei Risikogruppen unterteilt werden. Während in der Niedrig-Risikogruppe eine Beobachtung empfohlen wird und eine Röntgenuntersuchung in aller Regel entbehrlich ist, kann in der Mittel-Risikogruppe, je nach Befund, eine neurochirurgische Konsultation oder ein CT erforderlich sein. In der Hoch-Risikogruppe ist in den meisten Fällen eine CT unumgänglich und eine engmaschige Überwachung notwendig. Die native Röntgenaufnahme des Schädels ist nur in Ausnahmefällen indiziert, da eine unkomplizierte Fraktur keiner spezifischen Therapie bedarf und ein Normalbefund behandlungsbedürftige intrakranielle Verletzungen nicht ausschließt. Lediglich bei Verdacht auf Shuntdiskonnektion und bei Verdacht auf Kindesmißhandlung hat die Nativröntgenaufnahme eine Konsequenz. Die CT ermöglicht hingegen einen exakten Nachweis von Kontusionen, traumatischen Subarachnoidalblutungen, sowie epiduralen und subduralen Hämatomen. Bei schwerer klinischer Symptomatik stellt sie die Untersuchungsmethode der Wahl dar.SummaryOur contribution reviews the diagnostic algorithm of head injuries in children. According to the Heidelberg consensus on head injury, patients should be divided into three risk groups. In low-risk patients clinical observation is the method of choice and radiological examinations are usually unnecessary. Patients at medium risk should be observed carefully. Sometimes neurosurgical consultation or CT is necessary. High risk patients in most instances need CT and neurosurgical consultation. Skull X-ray is helpful only in selected cases. A simple fracture as demonstrated by skull X-ray has no therapeutic consequence. However, normal findings in skull X-ray do not exclude intracranial injury. CT is the method of choice to detect intracranial hemorrhage, epi- or subdural hematoma and cerebral contusion. If patients present with severe clinical deficits, CT allows characterization of lesions and initiation of specific therapy.

Internal jugular venous valves in children: high-resolution US findings.

Abstract The aim of this study was to determine in children the prevalence rate and to describe the sonographic morphology of the valves in the internal jugular veins. One hundred twenty children (60 boys and 60 girls; mean age ± SD 10 ± 4 years, age range 3–20 years) were recruited for the study. They underwent sonographic examination of both internal jugular veins. The number of valvular cusps, the length of the cusps and exact site of origin were recorded. In 96 % of the children a valve was found in one or both internal jugular veins. Within this group a valve was detected unilaterally in 26 % and bilaterally in 74 % of the cases. Ultrasound morphological and morphometric analysis was carried out in a total of 239 internal jugular veins; 200 (84 %) veins were found to have valves. The origin of the cusps was located at a mean distance of 9 mm (0–26 mm) proximal to the confluence of the subclavian and internal jugular veins into the brachiocephalic vein. A valve in the distal part of the internal jugular vein is a very common finding with characteristic features on US.

Akute hämatogene Osteomyelitis: Ausschluss mit Turbo-STIR-Sequenz?

ZusammenfassungEine schnelle effiziente Diagnostik ist bei der Frage nach einer akuten hämatogenen Osteomyelitis besonders wichtig, da der klinische Verlauf vorwiegend durch eine frühzeitige Diagnose und einen baldmöglichen Behandlungsbeginn bestimmt wird. Um den Stellenwert der Sequenzen einer magnetresonanztomographischen Untersuchung zu ermitteln, evaluierten wir in einer retrospektiven Studie die Bilder von 8 Kindern mit akuter juveniler Osteomyelitis, welche eine Untersuchung an einem 0,5-Tesla-Gerät erhalten hatten. Auf allen Bildern zeigte sich eine Intensitätserhöhung in der Turbo-STIR-Sequenz, in 7 von 8 Fällen war ein Kontrastmittelenhancement in einer T1-gewichteten Sequenz mit Fettunterdrückung nachweisbar. Die Turbo-STIR-Sequenz stellte sich als sensitivste Sequenz heraus. Ist in der Turbo-STIR-Sequenz kein hyperintenses Signal zu erkennen, kann eine akute Osteomyelitis ohne Durchführung weiterer Sequenzen ausgeschlossen werden.AbstractThe timely diagnosis and early initiation of antibiotic therapy determine the clinical course of an acute hematogenous osteomyelitis. Consequently, a fast and efficient MRI examination protocol is crucial. We retrospectively evaluated various MR sequences used in the examination of 8 children having osteomyelitis. The examinations were conducted using a 0.5 T MR machine. All patients had a high signal intensity of the lesion in the IR sequence with fat suppression (turbo-STIR). An acute osteomyelitis can be excluded in the absence of signal intensity increase in the turbo-STIR sequence without the necessity of having to perform additional sequences.

Imaging in osteomyelitis in the growing skeleton

SummaryIn acute osteomyelitis of childhood a rapid diagnosis and initiation of antibiotic therapy is necessary in order to prevent late sequelae. Thus, diagnostic imaging plays a crucial role. If acute osteomyelitis is suspected in a child, imaging starts with conventional radiography in order to exclude other differential diagnoses. This is followed by sonography for the purpose of diagnosing a subperiosteal abscess or joint fluid from which the causative organism could be isolated. If the diagnosis is unclear, the next step should be either MRI or 99m Tc-MDP bone scan, depending on the possibility of clinical localization and the site of the suspected lesion. MRI is superior to bone scan in depicting the exact anatomy, which is extremely important in spinal osteomyelitis and preoperatively. The bone scan can show the whole skeleton in one examination and should be favored if there is no definite localization or in suspected multifocal osteomyelitis. Rarely scintigraphy with labeled white blood cells is indicated. The 67 Ga scan, however, should not be used in children because of the high level of radiation exposure. The different imaging modalities are described in detail and an imaging diagnostic workup is outlined.ZusammenfassungDa bei akuter Osteomyelitis im Kindesalter ein früher Behandlungsbeginn zur Vermeidung von Spätschäden wichtig ist, muß die Diagnose so rasch wie möglich gestellt werden, wobei den bildgebenden Verfahren eine wesentliche Rolle zukommt. Eine sinnvolle Bildgebung bei klinischem Verdacht auf akute Osteomyelitis im Kindesalter beginnt mit dem Röntgenbild zum Ausschluß anderer Differentialdiagnosen und der Sonographie zum evtl. Nachweis punktierbarer subperiostaler Abszesse oder Gelenkergüsse, aus denen der Erregernachweis unmittelbar möglich wäre. Falls mit Röntgenbild und Sonographie kein pathologischer Befund zu erheben ist, sollte je nach klinischer Lokalisierbarkeit des Befundes und nach Lokalisation des vermuteten Entzündungsherdes eine Magnetresonanztomographie oder ein Szintigramm angeschlossen werden. Erstere hat Vorteile in der exakten anatomischen Darstellung und ist daher auch präoperativ wichtig, letzterem ist wegen der möglichen Beurteilbarkeit des gesamten Skelettes der Vorzug zu geben bei unklarem Lokalbefund oder bei multilokulären Prozessen. In seltenen Fällen kommt die Leukozytenszintigraphie zum Einsatz. Die Galliumszintigraphie hingegen sollte im Kindesalter wegen der höheren Strahlenbelastung möglichst vermieden werden. Die einzelnen Untersuchungsverfahren werden im Folgenden dargestellt und kritisch einander gegenübergestellt.