Evaluation of vasospasm secondary to subarachnoid hemorrhage with technetium-99m-hexamethyl-propyleneamine oxime (HM-PAO) tomoscintigraphy.

Vasospasm of intracranial vessels is difficult to diagnose on clinical ground alone. Still, a clear diagnosis is important because it can impact on surgical timing; and also because it can help evaluate new treatments. Fifteen patients with sub-arachnoid hemorrhage secondary to aneurysm rupture were submitted to a total of 26 tomographic technetium-99m-hexamethyl-propyleneamine oxime (99mTc-HM-PAO) brain examinations that were correlated with temporally close (generally less than 24 hr) angiography or transmission computed tomography (TCT). Nine of 10 angiographically confirmed episodes of spasm and 6 of 6 infarcts seen on angiography or TCT were correctly diagnosed with 99mTc-HM-PAO. One normal scintigraphic exam was angiographically doubtful, one positive 99mTc-HM-PAO study was normal on angiography (sub-radiologic spasm?), one technically poor scintigraphy was positive for spasm on angiograms, and eight exams were normal for spasm with all modalities. We had agreement between tests in 23 of 26 series of exams (88%) obtained in 15 patients. We think that 99mTc-HM-PAO tomography should be useful for the evaluation of patients with suspected vasospasm.

Combination drug therapy in treatment of Paget's disease of bone: clinical and metabolic response.

Twenty-seven patients with symptomatic Paget's disease of bone were randomly treated with mithramycin, glucagon, and calcitonin given either alone or in combination. Mithramycin, at a dose of fifteen micrograms per kilogram of body weight per day, proved to be a relatively safe drug and elicited a rapid response with only transient side effects. Calcitonin combined with mithramycin was the most effective therapy.

Dipyridamole testing compared to exercise stress for thallium-201 imaging in patients with left bundle branch block.

Because of numerous reports of false positive results with thallium-201 (Tl-201) stress testing in patients with left bundle branch block, the authors decided to evaluate another mode of coronary vasodilatation, dipyridamole, for the diagnosis of coronary atheromatosis. Nine patients were prospectively studied with stress and dipyridamole Tl-201 scintigraphy; both tests were performed within three to 79 days of one another. Five of the patients also had coronary angiograms (four within one year, one five years earlier). Four of the patients had normal results with both tests (two normal angiograms, two not performed); two had reversible septal defects with stress-induced coronary vasodilatation but normal dipyridamole studies (only one had an angiogram, which was normal); one patient had a fully reversible septal defect with stress and a fixed defect with dipyridamole (normal angiogram); one had a partially reversible septal stress defect which was fixed with dipyridamole; and one had a normal stress study but a reversible septal defect with dipyridamole (an angiogram performed five years earlier showed 30 to 40% stenosis of the anterior descending artery). Because it seems that dipyridamole produces fewer false positive results, it should be used instead of stress testing to induce coronary vasodilatation in patients with left bundle branch block.

[The role of echography in splenic injuries in children]. / Le rôle de l'échographie dans le traumatisme splénique chez l'enfant.

We have reviewed 39 cases of ruptured spleen in children from 1979 to march 1983 at Ste-Justine Hospital in Montreal. We were mainly interested in the role of ultrasonography, its value and limitations. The practical management is exposed. To the best of our knowledge, it is the first report of this kind in pediatrics.

[Scintigraphic aspect of infantile cortical hyperostosis (Caffey's disease)]. / Aspect scintigraphique de l'hyperostose corticale infantile (maladie de Caffey).

Two patients with infantile cortical hyperostosis (Caffey's disease) are presented in whom radionuclide imaging with 99mTc-MDP and 67Gallium-citrate was performed to eliminate multifocal osteomyelitis as a diagnosis. The scintigraphic appearance of this relatively uncommon disease of children was similar to that obtained in multifocal osteomyelitis; all osseous lesions showed a marked uptake of both radiotracers. However, the distribution of abnormalities (mandible, scapulae) and the degree of extension (mainly diaphyseal) of the lesions are important characteristics in the scintigraphic differential diagnosis but bone radiographs are best used in making the diagnosis.

Transitional neonatal hydronephrosis: fact or fantasy?

Hydronephrosis secondary to an anomalous ureteropelvic junction was detected antenatally in more than 60 neonatal renal units Those 21 units that exhibited partial obstruction or dilatation without obstruction were selected for this study. They were assessed and followed by serial diuretic isotope renography (99mtechnetium-diethylenetriaminepentaacetic acid augmented with furosemide) and ultrasonography. Excretory urography was used selectively. Of the 17 renal units that could be assessed 88 per cent demonstrated labile ureteropelvic junctions. Indeed, in 3 to 6 months, when the definitive status seemed to be attained, 41 per cent (7 units) had deteriorated, 12 per cent (2 units) remained stable and 47 per cent (8 units) underwent spontaneous improvement. We recommend a 3 to 6-month observation period for patients with hydronephrosis secondary to ureteropelvic junction anomalies when definite obstruction cannot be confirmed by isotope renography.

Nephrosis with varicocele: probable renal vein thrombosis.

A 3-year-old boy with relapsing nephrosis presented with a left sided varicocele. Echographic studies demonstrated enlargement of the left kidney, and there was delayed excretion on renal scintigraphy suggesting the presence of renal vein thrombosis. The varicocele resolved with remission of his nephrosis.

Posttransplantation complications of lower limb polytetrafluoroethylene grafts in children.

Two children had polytetrafluoroethylene (PTFE) arteriovenous thigh grafts for hemodialysis access. In one patient, after renal transplantation, a steal syndrome, which prevented renal graft function, developed. The renal transplant functioned promptly when the vascular graft was ligated. In the second case, acute thrombosis of the PTFE graft resulted in transient hypertensive encephalopathy. PTFE thigh grafts, because of the diversion of a large percentage of cardiac output through them, may have dramatic and dangerous consequences in transplanted children.

[Chondromyxoid fibroma: radiologic and radioisotope aspects]. / Fibrome chondromyxoïde: aspects radiologique et radio-isotopique.

Chondromyxoid fibroma is a relatively rare benign bone tumor whose histologic and radiologic patterns are well known. In this article, we describe a 16-year-old boy with such a tumor in his left tibia. Scintigraphically, this tumor is represented by a "doughnut sign". This aspect, though not pathognomonic, has been reported sporadically in a few diseases: osteoporosis circumscripta cranii, angioblastic meningioma, cranial coccidioidomycosis, and aseptic necrosis of frontal bone. Because of their sites, it is easy to reject these diagnoses in our patient. The most pertinent differential diagnosis with regard to the clinical, radiological, and scintigraphic aspects in the patient is that of a giant cell tumor.

[Splenic injuries: therapeutic orientation. Apropos of 46 cases]. / Traumatismes spléniques: orientation thérapeutique. A propos de 46 cas.

Between 1979 and june 1983, 46 splenic trauma, with or without associated lesions, have been treated at Sainte'-Justine's Hospital. 8 children had a splenectomy, 3 had a laparotomy for other lesions without a splenectomy was done. 35 had a non operative management of splenic trauma. The ultrasound shows the splenic lesions and the blood in the peritoneal cavity. So, the "Routine Abdominal TAP" does not seem necessary in every abdominal trauma. The splenic scintigraphy is, for, now, the best exam to confirm the diagnosis and to assess the resolution of splenic lesion in 1 to 4 months. Transfusions were done in 8 of 11 operated patients and in 11 of the 35 children wo underwent a conservative management. The average stay in the hospital was 11 days in these 35 last patients. No mortality or morbidity were in relation with the conservative management in our series. The exact diagnosis of splenic trauma by ultrasound and scintigraphy allows the pediatric surgeon to choose a non operative treatment, when the child has stable vital signs. Monitoring these patients in intensive care unit is mandatory and allows a careful evaluation of the course of these splenic trauma.

Intermittent hydronephrosis: a diagnostic challenge.

Intermittent hydronephrosis is a difficult condition to diagnose because of the mild degree of dilatation encountered in imaging studies. The condition nevertheless is disabling and attempts to reach a precise diagnosis include diuretic excretory urography, ultrasonography and renal scans. The delayed double-peak pattern seen on 99mtechnetium-diethylenetriaminepentaacetic acid diuretic renography shows how the ureteropelvic junction can become self-obstructing with forced diuresis. All patients who exhibited this sign eventually had frank obstruction and most exhibited an extrinsic component to the obstruction. The recognition of the double-peak pattern may become a useful adjunct in the early diagnosis of intermittent hydronephrosis.

[Hepatobiliary scintigraphy using 99m Tc-DISIDA and obstructive cholangiopathy in children]. / Scintigraphie hépato-biliaire au disida-99mTc et cholangiopathies obstructives infantiles.

Technetium 99m-labeled diisopropyl iminodiacetic acid (99m Tc-DISIDA) hepatobiliary scintigraphy of 26 patients with pathologically proven infantile obstructive cholangiopathy are retrospectively studied according to two types of criteria. Those of type 1 consider 1) hepatocyte clearance 2) hepatobiliary transit time and 3) visualisation of intestinal activity. For biliary atresia, sensitivity of 88.2%, specificity of 88.9%, positive predictive value of 93.8% and negative predictive value of 80.0% were obtained. For neonatal hepatitis, those parameters were 57.1%, 94.7%, 80.0% and 85.7% respectively. Criteria of type 2 identify only biliary atresia. They consider 1) presence or absence of intestinal radioactivity through 24 hours and 2) birth weight. Sensitivity, specificity, positive and negative predictive values were 88.2%, 88.9%, 93.8% and 80.0% respectively. Even if all these values are inferior to many reported in literature, we consider that the two types of criteria are relatively sensitive and specific to detect biliary atresia. Even through there are a few false negatives, biliary scintigraphy does remain one of the most important diagnostic tests in the context of biliary atresia.

[Compulsory internship in diagnostic radiology in the 5th year of medicine at the University of Montreal]. / Pasantía obligatoria de radiología diagnóstica en el quinto año medicina de la Universidad de Montreal.

Problems of methodology, organization, and evaluation confronting the radiology departments of the university hospitals affiliated with the University of Montreal, the medical students, and the University itself in connection with an elective internship in radiology offered in the fifth year of medicine, resulted in the formation of a committee to reorganize the course of study. In this concise article the authors describe this and other measures taken by the University to solve these problems. The committees' main purpose was to restructure the internship which was made compulsory so that future physicians would be prepared to draw on the resources of diagnostic radiology and nuclear medicine. To this end, the committee formulated the objectives, content, evaluation system, and pedagogical methods to be used in those courses. The 25 self-teaching modules, together with the observation and practical interpretation of radiology sessions, proved highly useful in solving the initial problems, and were of particular interest to the students.

Synoviorthesis with colloidal 32P chromic phosphate for hemophilic arthropathy: clinical follow-up.

Thirty-one synoviortheses were performed in 22 joints of 14 hemophilic patients (aged 12 to 28 years) with chronic synovitis and for whom "conventional treatments" were considered ineffective. Except for patients with inhibitors, conventional treatments included three to six months of adequate prophylactic therapy with the missing coagulation factors, intensive physiotherapy and, when indicated, antiinflammatory agents and orthosis. Colloidal 32P chromic phosphate was injected intraarticularly in doses of 1.0 mCi for knees and of 0.5 mCi for the other joints. Time of follow-up ranged from two to five years. Frequency and importance of bleeding decreased in all patients. Effect on range of motion was best in knees; six of the seven treated improved and one was unchanged. In elbows, flexion-extension was improved in four cases, unchanged in five and decreased in one; pronation-supination was decreased in four cases. Range of motion was not affected in shoulders and ankles except for internal-external rotation which was improved in two of three shoulders treated. The results of 13 synoviortheses in four hemophilic patients with high titer factor VIII inhibitors were comparable to those in hemophiliacs with no inhibitors. However, in three of the four patients synoviorthesis had to be repeated after two to four years for recurrence of synovitis. Extraarticular escape of radioactivity was monitored 62 times for 17 synoviortheses in 12 patients; extraarticular counts never exceeded 4% of the intraarticular counts. Chromosome aberrations were found not to be increased after treatment in the seven patients in whom adequate analysis could be done.