Outpacing movement - ultrafast volume coverage in neuropediatric magnetic resonance imaging.

BACKGROUND: Conventional MRI sequences are often affected in neuropediatric imaging by unavoidable movements. Therefore, children younger than 6 years usually have to be examined under sedation/anesthesia. A new real-time MRI technique with automatic slice advancement allows for motion-robust T2-weighted volume coverage of the whole brain within a few seconds in adults. OBJECTIVE: To evaluate to which extent the new volume coverage method can be used to visualize cerebrospinal fluid and reduce the need for anesthesia in children. MATERIALS AND METHODS: We assessed 30 children ages 6 years and younger with suspected or proven hydrocephalus, hygroma or macrocephalus using volume coverage sequences with 20 slices per second in three planes. If necessary, a parent was placed in the bore together with the child for calming and gentle immobilization. We compared visualization of cerebrospinal fluid spaces and course of the shunt catheter in volume coverage sequences vs. fast spin-echo sequences. RESULTS: The clinical issue could be sufficiently assessed in all children with use of volume coverage sequences, whereas conventional fast spin-echo sequences performed moderately to poorly. Visualization of the tip of a shunt failed in 16% of volume coverage scans and 27% of turbo spin-echo scans. A subsequent examination under anesthesia was never necessary. None of the examinations had to be stopped prematurely. CONCLUSION: The motion-robust volume coverage sequences with T2-type contrast can be used to avoid sedation of children in the evaluation of cerebrospinal fluid spaces, even in the presence of vigorous motion. For other indications and contrasts, the technique must still be evaluated.

The effects of long-term medical treatment combined with clean intermittent catheterization in children with neurogenic detrusor overactivity.

OBJECTIVES: To assess whether conservative treatment of pediatric patients with neurogenic detrusor overactivity (NDO) results in lower bladder pressure and increased expected bladder volume (EBV), we investigated the clinical and urodynamic effects of long-term intravesical oxybutynin instillation compared with a standard treatment of oral anticholinergic medication in patients with clean intermittent catheterization (CIC). METHODS: A retrospective study was performed including 21 patients suffering from myelomeningocele and NDO. Initially, all patients were treated with oral anticholinergics and CIC. Ten of the 21 patients showed a sufficient response to the treatment and were included in group I (anticholinergics and CIC). The other 11 patients responded poorly to the initial treatment or developed side effects to oral medication. These patients were included in group II and treated with intravesical oxybutynin and CIC. The two groups were compared using clinical, sonographic and urodynamic examinations performed prior to starting treatment and repeated on an annual basis. Changes from baseline were analyzed with the Mann-Whitney U test. RESULTS: Ten patients in group I and 11 in group II were investigated. Two of the 11 patients in group II stopped the treatment. The mean starting age was 8.1 (± 6.6) years in group I and 12.5 (± 4.5) years in group II. The mean follow-up time was 7.1 (± 5.5) years in group I and 3.6 (± 1.8) years in group II. Bladder capacity increased from 173 (± 99) to 371 (± 115) ml in group I and from 245 (± 133) to 370 (± 156) ml in group II. Six of the 10 patients in group I and 6/9 patients in group II reached normal EBV. Three of the 10 subjects in group I and 6/9 in group II had bladder compliance values >10 ml/cm H(2)O. At final follow-up, the overall rate of urinary tract infections was equal. Social continence was achieved in 6/10 in group I and 7/9 in group II. Altogether, 19/21 patients responded to conservative management. CONCLUSIONS: In children with NDO, conservative medical treatment combined with CIC is feasible and provides an improved pattern of bladder function, which could help avoid bladder surgery.

Congenital myelomeningocele - do we have to change our management?

BACKGROUND: Eagerly awaiting the results of the Management of Myelomeningocele Study (MOMS) and with an increasing interest in setting up intrauterine myelomeningocele repair (IUMR), the optimal management of patients suffering from congenital myelomeningocele (MMC) has become a matter of debate again. We performed a cross-sectional study at our referral-center for MMC to determine the outcome for our expectantly managed patients. MATERIALS AND METHODS: A computed chart review at our institution revealed 70 patients suffering from MMC. Forty-three patients were eligible for the study and analyzed further. A retrospective analysis was performed only in patients that underwent MMC repair within the first two days of life and were seen at our outpatient clinic between 2008 and 2009 for a regular multidisciplinary follow-up. Data were collected on: gestational age (GA) and weight at birth, age at shunt placement and shunt status after the first year of life, radiological evidence for Arnold-Chiari malformation (ACM) and tethered cord (TC), need for surgery for TC, bladder function, lower leg function and educational level. Data were compared to published results for IUMR and to studies of historical controls. RESULTS: Patients were born with MMC between 1979 and 2009 and are now 13.3 ± 8.9 (mean ± SD) years of age. At birth, mean GA was 37.8 ± 2.3 weeks and mean weight was 2921.3 ± 760.3 g, both significantly higher than in IUMR patients. Shunt placement in our cohort was required in 69.8% at a mean age of 16.0 ± 10.7 days, which was less frequent than for historical controls. Amongst our cohort, radiological observations showed 57.1% had ACM II and 41.9% had TC. Only two of our patients underwent a surgical correction for TC. Clean intermittent catheterization was performed in 69.7% of our patients, 56.4% were (assisted) walkers and 64.1% attended regular classes, both comparable to historical controls. CONCLUSIONS: With a close and interdisciplinary management by pediatric surgeons, neurologists and urologists, the long-term outcome of patients suffering from MMC can currently be considered satisfactory. With respect to the known drawbacks of fetal interventions for mother and child, especially preterm delivery, the results of the MOMS trial should be awaited with caution before proceeding with a complex intervention like IUMR.