Shaimaa Abdelsattar Mohammad

MRI of persistent cloaca: Can it substitute conventional imaging?

PURPOSE To define the role of MRI in the preoperative assessment of patients with persistent cloaca and whether it can substitute other imaging modalities. METHODS We prospectively examined eleven patients with persistent cloaca between July 2007 and March 2012. Non contrast MRI examinations were performed on 1.5T magnet using head coil. Multiple pulse sequences (T1WI, T2WI, fat suppression) were obtained in axial, sagittal and coronal planes of the pelvis, abdomen, and spine. The scans were reviewed for the following: the level and type of rectal termination, the developmental state of striated muscle complex (SMC), associated genitourinary and spinal anomalies. MRI findings were compared to conventional fluoroscopic imaging, operative and endoscopic findings. We applied novel MRI parameters (urethral length, relative hiatal distance and vaginal volume). The relation between different parameters was tested statistically using Pearson correlation test. RESULTS MRI could accurately demonstrate the level of bowel termination in patients with persistent cloaca, in addition to its high sensitivity for detection of mullerian anomalies which were present in 73% of patients. Furthermore, MRI could disclose associating renal and spinal anomalies, and assess the developmental state of SMC. The shorter the urethra (higher urogenital confluence), the narrower the pelvic hiatus, and the more was the obstruction (vaginal distension). CONCLUSION MRI is a valuable tool in exploring the different internal anatomical features of the cloacal anomaly; and when combined with endoscopy, MRI can make other preoperative conventional imaging unnecessary.

Y-Type Urethral Duplication: A True Variant of the Anomaly or a Misnomer?

Objectives The objective of this study was to define anatomical and radiological features of the so-called Y-type urethral duplication. Methods The study included four male patients and one female patient with congenital connection between the urogenital tract and the external anal orifice. Investigations included renal sonography, urethrograms, and magnetic resonance imaging pelvis in the last patient. The urethrograms of male patients were carefully reviewed, in addition to available urethrograms of similar cases that could be obtained through searching the literature. Results Unlike cases of urethral duplication, the male patients had always a complete prepuce and a functioning anterior urethra in 25%. The accessory uroanal channel had almost always a constant origin from the posterior urethra. Some tension seems to be exerted by the urethroanal tract pulling on and causing a kink in the posterior urethra. Management was simple in patients without anterior urethral hypoplasia (one male and the female patient). Both were treated by simple excision of the communicating ano-urogenital tract through a perineal approach with an excellent outcome. Histopathological examination of excised tracts revealed stratified squamous cell in the former and transitional cell lining in the latter. In patients with hypoplastic anterior urethra, staged urethral reconstruction was performed in two, and progressive dilatation of hypoplastic anterior urethra was tried in the last patient. Conclusion Several observations would support diagnosing the congenital connection between the urinary tract and the external anal orifice in the male as a congenital fistula rather than an accessory urethra. Confirming and accepting this information may have its impact on changing the current surgical approach.

Low-type anorectal malformations in the male: Extent of deviation from the norm.

PURPOSE To define the degree of deviation from the norm among boys with minor forms of anorectal malformations (ARM). PATIENTS AND METHODS Between March 2015 and January 2016, we studied the preoperative MRI of nine boys with low-type ARM. For comparison, we included another nine boys (control group) who underwent MRI pelvis for causes other than ARM (e.g. impalpable testes). RESULTS In boys with low-type ARM, the rectum descends forwards to touch the back of the prostate (as in the norm), but then goes downwards (with little or no backward deflection) keeping intimately attached to the bulb of the corpus spongiosum and displacing it downwards and forwards. The striated sphincter muscles do not follow the anterior displacement of the bowel termination, but remain orthotopically compacted at the normal predestined site of the anal canal. CONCLUSION Among boys with low ARM, the minor abnormalities at the external anal orifice are associated with deeper anatomical aberrations in the form of anterior misplacement of the anorectum. These findings may help in understanding the disturbed act of defecation among these patients, and provide guidance to the best way of surgical correction.

Magnetic resonance imaging of developmental facial paresis: a spectrum of complex anomalies

PurposeDespite its clinical implications, the MRI features of developmental facial paresis (DFP) were described in a few case reports. This study aims to describe MRI features of DFP in relation to the embryological development with a proposed radiological new grading system.MethodsThe clinical records and MRI of the brain and internal auditory canal of 11 children with DFP were retrospectively reviewed. The following sequences were analyzed: axial, oblique sagittal SPACE of the internal auditory canal and brainstem; axial T2, T1WI and coronal T2WI of the brain. The severity of the maldevelopment of the seventh nerve was graded from 0 to 4: 0 = no abnormalities, 1 = unilateral facial nerve hypoplasia, 2 = unilateral facial nerve aplasia, 3 = aplasia or hypoplasia involving facial nerves on both sides, and 4 = facial nerve aplasia or hypoplasia associated with other cranial nerve palsy.ResultsIsolated facial nerve palsy was diagnosed in seven patients. It was of grade 1 in five and grade 3 in two. Hypoplasia of the nerve with interrupted course was encountered in two cases. Other associated cranial nerve abnormalities (grade 4) were seen in four patients; two of them were diagnosed previously as Moebius syndrome. In addition to inner ear anomalies, middle and external ear and parotid gland anomalies were described.ConclusionTo our knowledge, this is the largest series of patients with DFP that represents a continuum of isolated and combined malformations. Understanding of embryological basis can give insights into the anomalous development of the facial nerve.

Anatomical alterations following the ‘PSARP’ procedure: Correlating MRI findings with continence scores

PURPOSE To identify anatomical aberrations following PSARP procedure by using MRI, while correlating MRI findings to clinical outcome. PATIENTS AND METHODS Between January 2014 and December 2017, we conducted our study on male patients with rectourethral fistula who underwent PSARP. Postoperative pelvic MRI studies were performed and correlated to their clinical continence scores (Rintala, and Krickenbeck classification). RESULTS The study included 31 patients. Fourteen patients were retrieved from the hospital records and accepted to participate in the study; while the remaining 17 were collected from the fecal incontinence clinic. Their age ranged from 40 to 156 months (mean 83) We divided patients in the study into two groups according to their Rintala continence scores: (Group A) 15 patients with low scores (10 or less); and (Group B) 16 patients with higher scores (more than 10). We detected wider pelvic hiatus (hiatus/PC ratio) and more obtuse anorectal angle in group A than B. CONCLUSION Several anatomical alterations can be detected by MRI following the PSARP procedure that include abnormalities in the striated muscle sphincter (attenuation/deficiency), deviated neorectum, and presence of excessive perirectal fat. A widened pelvic hiatus and/or obtuse anorectal angle may correlate with poor fecal continence in these patients. LEVEL OF EVIDENCE This is a case control study (level III evidence).

Magnetic resonance imaging of head and neck vascular anomalies: pearls and pitfalls

Purpose The aim of this study was to describe typical MRI features of the head and neck vascular anomalies and the possible diagnostic pitfalls. Patients and methods Patients with extracranial vascular anomalies of the head and neck, who underwent MRI examinations between January 2013 and January 2016, were included in the study. Precontrast and postcontrast T1-WI, T2-WI, with and without fat saturation were acquired. When indicated, a noncontrast MR angiography was performed. Dynamic postcontrast MRI techniques were available in six children. Results The study included 33 patients (age ranged from 10 to 20 years, mean: 49 months). MRI confirmed the clinical diagnosis in equivocal cases, and provided proper determination of lesion extension and/or associated intracranial anomalies. The study included 10 cases of vascular tumors (hemangioma), whereas the remaining 23 cases had the diagnosis of vascular malformations (one patient with arteriovenous malformation, one with capillary malformation, seven with venous, nine with macrocystic lymphatic, and five with microcystic lymphatic malformations). Conclusion Vascular anomalies in the head and neck are mostly diagnosed on clinical basis; however, when the history is uncertain or the diagnosis is equivocal, a well-tailored MR examination can be a single valuable diagnostic tool providing structural and functional information.

The double urethra: revisiting the surgical classification.

Aim: The aim of this article was to describe our experience with 14 patients with double urethra. Patients and methods: We retrospectively examined the patients’ records including their clinical presentations, investigations, operative findings, and outcome. In addition to Effmann’s classification, we used a newly proposed classification that depends on the orientation of the double urethral channels. Results: During the last 15 years, 18 patients were diagnosed to have double urethra at our pediatric surgical unit. We excluded four patients with ‘Y-type’ urethral duplication. The remaining 14 patients were divided into either sagittal or collateral duplication. Their age at presentation ranged from the neonatal period to 9 years. The sagittal urethral duplication included 12 male patients. All patients had two urethral channels, one above the other. The dorsal urethral channel was always characterized by poor function and ectopic course. The ventral channel was always the more functioning urethra, with a normal course from the urinary bladder to end either at an orthotopic meatus (subgroup A), or more proximally in a hypospadiac location (subgroup B). The collateral urethral duplication included two patients. Both patients were associated with duplication of the urinary bladder and the external genitalia as a part of caudal duplication syndrome. In this group, both urethrae had comparable function, lying side by side, and each draining a separate urinary bladder. Conclusion: The double urethra is a diverse spectrum comprising different pathologies. Our proposed classification system of duplicated urethras is clinically relevant as it guides surgical management and allows prognostication of outcome.

The radiological assessment of colonic replacement of the esophagus in children: A review of 43 cases.

PURPOSE To define the characteristic radiological features following colonic replacement of the esophagus in children. MATERIALS AND METHODS The upper gastro-intestinal contrast studies of 43 patients who underwent colonic replacement of the esophagus at our pediatric surgery unit were available for analysis. UGI contrast studies were performed routinely in the post-surgical period in 17 cases (first asymptomatic group), while the rest of contrast studies (26) belonged to a second group of out-patients complaining of dysphagia (18) or dyspepsia (8) following colonic replacement of the esophagus. Based on our observations, we proposed a grading system to describe the degree of colonic redundancy in the thorax. RESULTS Redundancy of the colonic conduit in the thoracic cavity was a common radiological finding (62.8%). The redundancy was mild (grade 1) in 18 patients, moderate (grade 2) in eight, and severe (grade 3) in only one patient. In 88.9%, the redundancy was in the right hemi-thorax. Patients presenting with postoperative dysphagia had a stricture at the site of the esophago-colic anastomosis in the neck, which should be differentiated from other sites of anatomical narrowing at the inlet and outlet of the thoracic cavity. Gastro-colic reflux was common among patients who underwent colonic replacement of the esophagus without an anti-reflux procedure. CONCLUSION Colonic replacement of the esophagus in children results in considerable anatomical alterations. Knowledge about the normal post-surgical changes and imaging features of the commonly encountered complications can increase the diagnostic confidence among radiologists and clinicians when dealing with these cases.

The second trial pneumatic reduction for idiopathic intussusception: therapeutic effect and hazards

PurposeTo study the therapeutic effect of the second trial pneumatic reduction on patients with idiopathic intussusception. Patients and methodsA prospective study was carried out on patients with idiopathic intussusception presenting to our unit, between August 2009 and January 2010. We excluded patients older than 2 years of age, neglected cases with signs of peritonitis, and recurrent cases. All patients were subjected to the first trial pneumatic reduction, which was performed in three successive attempts (3 min each) under fluoroscopic guidance with pressure ranging from 80 to 100 mmHg. Patients with incomplete reduction but with satisfactory movement of the intussusceptum in the first trial were subjected to a second trial pneumatic reduction after 3 h. ResultsFifty patients underwent first trial pneumatic reduction, which was successful in 33 patients, representing an overall reduction success rate of 66%. Of the remaining 17 patients, nine immediately underwent surgery rather than undergoing a second trial of pneumatic reduction because of minimal movement of the intussusceptum during the first trial. A second trial pneumatic reduction was offered to the remaining eight patients and was successful in six (75%), increasing the overall success rate from 66 to 78%. There were no bowel perforations among all the attempts at pneumatic reduction (first or second trials). ConclusionIn a selected group of patients, delayed repeated air enema can increase the nonoperative reduction rate of idiopathic intussusception; however, careful attention should be paid towards decreasing exposure to radiation.