Laser ablation of embryonic veins in children.

BACKGROUND: Klippel-Trenaunay syndrome (KTS) and related overgrowth syndromes are rare conditions that often present to academic pediatric units and multidisciplinary vascular anomaly clinics. These conditions are commonly associated with abnormalities of the superficial and deep venous structures and carry an increased risk of venous thromboembolism. METHODS: A retrospective chart review was completed of all patients treated at Johns Hopkins All Children's Hospital with endovenous laser ablation therapy (EVLT) for management of dilated embryonic veins in the setting of limb overgrowth. RESULTS: Three patients with limb overgrowth underwent EVLT between 2015 and 2017. All patients had successful occlusion of the targeted veins on post-procedure imaging. One patient developed a cellulitis successfully treated with oral antibiotics. CONCLUSIONS: Endovenous laser ablation therapy is a well-tolerated and safe procedure for prophylactic closure of abnormal superficial embryonic veins. This study supports the use of this technique in managing increased thromboembolic risk in this unique patient population and recognizes the need for a long-term study to determine its efficacy.

Alveolar soft-part sarcoma: Case demonstrating principles for uncommon vascular lesions.

BACKGROUND: Alveolar soft-part sarcoma (ASPS) is an uncommon malignancy that may present in a manner similar to benign vascular tumors. METHODS: A 6-year-old boy with autism spectrum disorder was referred to the Johns Hopkins All Children's Hospital vascular anomalies clinic for the evaluation of a tongue mass. RESULTS: Prior to the presentation, at 5 years of age, neck computed tomography (CT) was performed. This showed a well circumscribed, enhancing mass at the anterior aspect of the tongue. The radiologic impression was that this lesion was most likely a hemangioma. Two years later, the patient was evaluated in the vascular anomalies clinic. At that examination a 2-3 cm swelling was noted on the dorsal aspect of the tongue. The mass was fleshy and firm with discrete borders. Handheld Doppler examination indicated a high-flow lesion. The patient underwent an excisional biopsy. The lesion was identified as an alveolar soft-part sarcoma based on pathologic characteristics. CONCLUSION: Familiarity with common vascular tumors and malformations allows providers to diagnose the majority of these lesions on a combination of clinical history and physical examination. Atypical and combined lesions do benefit from imaging to help characterize and aid in the differential diagnosis. Biopsy enables definitive diagnosis but is necessary in the minority of cases. When in doubt, referral to a specialized, multidisciplinary vascular anomalies clinic will ensure that these patients receive management for this challenging collection of conditions.

Traumatic abdominal aortic dissection in a 16-month-old child.

Abdominal aortic injury after blunt trauma is rare in the pediatric population. There have been fewer than 20 reported cases in the literature since 1960, and most were the result of motor vehicle collisions. We report the case of a 16-month-old boy who is the youngest reported patient to sustain this type of injury. We discuss the radiologic findings in multiple imaging modalities, mechanisms, associated injuries and management options.

Radiation exposure from pediatric head CT: a bi-institutional study.

BACKGROUND: Medical radiation from CT should be kept as low as reasonably achievable (ALARA), particularly in young patients. OBJECTIVE: To examine radiation dose from head CT in children in a trauma center (TC) and a regional children's hospital (RCH). MATERIALS AND METHODS: A random sample of 240 children (0-3, 4-9, 10-14 years of age) from the TC were compared with a similar cohort from the RCH. All children had undergone at least one head CT scan without contrast enhancement; data from PACS and Department of Radiology Information System were used to estimate normalized effective dose (ED). Lifetime attributable risk of cancer incidence was estimated using the Biologic Effects of Ionizing Radiation (BEIR) VII report. RESULTS: The mean normalized ED was significantly higher in the youngest children at the TC (2.74 mSv in those aged 0-3 years vs. 2.23 mSv in those aged 10-14 years; P<0.001) and at the RCH (2.44 mSv in those aged 0-3 years vs. 1.71 mSv in those aged 10-14 years; P<0.001). Each decreasing year of age was independently associated with a 0.06 mSv higher mean normalized ED (P<0.001). After adjusting for the age difference between the institutions, the mean normalized ED was 0.44 mSv lower at the RCH than at the TC across all ages (95% CI 0.31-0.58, P<0.001). A higher lifetime attributable risk of cancer was associated with younger age. CONCLUSION: The radiation dose from head CT in children as defined by the normalized ED was highest in the youngest children and varied significantly between institutions in this bi-institutional study.

Interventional radiology and the care of the pediatric oncology patient.

Interventional radiology has become increasingly involved in the diagnosis and management of the pediatric oncology patient. Percutaneous biopsy and needle aspiration can be performed for solid and liquid lesions with image guidance, both for the primary diagnosis and for management of sequelae of cancer therapy. Therapeutic options also can be performed with image guidance, including radiofrequency ablation and transarterial chemoembolization. When surgical resection is required, image guided tumor localization can be used to aid in identifying small lesions.

How We Manage Pediatric Deep Venous Thrombosis.

Over the past two decades, the incidence and recognition of venous thromboembolism (VTE) in children has significantly increased, likely as a result of improvements in the medical care of critically ill patients and increased awareness of thrombotic complications among medical providers. Current recommendations for the management of VTE in children are largely based on data from pediatric registries and observational studies, or extrapolated from adult data. The scarcity of high-quality evidence-based recommendations has resulted in marked variations in the management of pediatric VTE among providers. The purpose of this article is to summarize our institutional approach for the management of VTE in children based on available evidence, guidelines, and clinical practice considerations. Therapeutic strategies reviewed in this article include the use of conventional anticoagulants, parenteral targeted anticoagulants, new direct oral anticoagulants, thrombolysis, and mechanical approaches for the management of pediatric VTE.

Predicting radiology resident errors in diagnosis of cervical spine fractures.

RATIONALE AND OBJECTIVES: Our objective was to identify factors associated with resident errors of cervical spine fractures to enable targeted education. MATERIALS AND METHODS: We performed a retrospective cohort study of consecutive cases of after-hours resident interpreted cervical spine fractures over 27 months at a single level 1 academic trauma center. The outcome measure was appropriate identification of all fractures by the resident. Potential predictors of resident error or discrepancy were identified from chart review and included: age, gender; fracture location/pattern (upper/lower cervical spine, occipital condyle, C1 ring, dens, C2 pars, vertebral body, posterior column, lateral mass, transverse process); consecutive and nonconsecutive additional fractures; radiologist distracting factors (number of noncervical spine injuries); number of noncervical spine studies performed. Risk ratios with confidence intervals were calculated for categorical variables using epidemiological 2 x 2 tables, and for continuous variables using difference of means. RESULTS: There were 59 errors among 492 cervical spine fractures in a total of 327 patients. Fifty-seven of the errors were on computed tomography and 2 errors were on radiographs. Upper cervical fractures were significantly more likely to have been errors than lower cervical fractures: risk ratio (RR) of 2.2 (confidence intervals (CI) 1.3, 3.5; P = .001). Occipital condyle fractures were more likely to have been discrepant: RR = 2.2 (CI 1.3, 3.9; P = .006). Dens fractures were also significantly more likely to have been discrepant: RR = 2.0 (CI 1.0, 3.8; P = .05). Other potential predictors were not associated with significantly increased risk. CONCLUSION: Upper cervical spine fractures, in particular occipital condyle and dens fractures were significantly associated with an increased relative risk of resident missing or misinterpreting the fracture. These findings suggest that resident education should focus in particular on upper cervical spine injuries, occipital condyle, and dens fractures. The methods used in this study could also be applied to other imaging modalities and anatomic regions in the future to target resident education to more challenging areas.

Gonadal vein embolization: treatment of varicocele and pelvic congestion syndrome.

Therapeutic embolization of the gonadal veins is performed on male and female patients for different clinical situations using similar techniques. The testicular varicocele is a common clinical problem associated with pain and reduced fertility rates. In women, chronic pelvic pain can be attributed to pelvic congestion syndrome, which is said to result from retrograde flow in incompetent ovarian veins. Both of these clinical problems respond well to gonadal vein embolization. In this article, we review the clinical evaluation, diagnostic workup, and technical aspects of percutaneous intervention of gonadal vein embolization. The supporting literature is also reviewed.

Imaging and percutaneous treatment of vascular anomalies.

Vascular anomalies are an extensive group of malformations of the arterial, venous, and lymphatic systems, either in isolation or, more often, in combination. Although mostly congenital, they can occasionally be acquired as well. They present a challenge both for workup and therapy. This article attempts to describe some of their main anomalies, their workup, and their therapies, with the goal of increasing the comfort level of endovascular therapists.

Multidetector CT angiography of pediatric vascular malformations and hemangiomas: utility of 3-D reformatting in differential diagnosis.

BACKGROUND: Vascular malformations can be difficult to diagnose and classify. Accurate classification is important because treatments and prognosis vary based on the type of lesion. Diagnosis is based on a combination of clinical features with a variety of imaging techniques, including US, MRI/MRA, CT, and conventional angiography. OBJECTIVE: We hypothesized that imaging features seen on 3-D reformatted images obtained with multidetector CT angiography (CTA) would aid in differential diagnosis of types of vascular anomalies. MATERIALS AND METHODS: We retrospectively reviewed CT scans of 11 patients with vascular lesions and pathologically proven diagnoses in which 3-D reformatting was obtained. RESULTS: The 3-D images accurately diagnosed hemangiomas and lymphangiomas in all cases, in contrast to diagnosis by clinical criteria and planar CT, which was difficult or inaccurate. The 3-D CTA did not aid in the distinction between venous malformations and arteriovenous malformations (AVM), which appeared similar. CONCLUSIONS: Our preliminary observations suggest that volume-rendered reformatting is helpful in categorizing clinically significant vascular head and neck lesions, resulting in more diagnostic value than planar CT imaging alone. In particular, 3-D CTA might allow accurate differentiation of hemangiomas from AVM, and of lymphangiomas from other types of lesions, which was, in our series, not possible using clinical examination or conventional planar CT angiography.

Ultrasound-guided endovenous diode laser in the treatment of congenital venous malformations: preliminary experience.

The authors present their experience in treating congenital venous malformations with ultrasound (US)-guided endovenous diode laser. Six patients underwent treatment of eight venous malformations for complaints including pain, activity limitation, or cosmetic defect. At a mean follow-up interval of 14.5 months, all had either resolution of (five patients) or marked decrease in (one patient) pain, allowing them to resume previously limited activities. There were no instances of nerve damage or skin necrosis. One patient had a self-limited mucosal tongue base ulcer. In this small series of patients, endovenous laser treatment of venous malformations was effective during short-term follow-up.