Thallium-201 myocardial imaging in children.

The clinical applications of thallium-201 scintigraphy are less well defined in children than in adults. However, the published data indicate several potential applications including assessment of: 1) deficit in left ventricular myocardial perfusion, 2) early right ventricular volume or pressure overload, or both, and 3) the right ventricle in both cyanotic and acyanotic congenital heart disease. In this report, the applications of thallium imaging to pediatric diseases are described and the advantages and disadvantages of the procedure are enumerated.

Pediatric metrizamide ventriculography.

Although computerized cranial tomography (CT) is useful for the diagnosis of hydrocephalus and various fluid-containing intracranial cysts. CT cannot always define the functional relationship of the cyst to the normal CSF pathways. In such cases, ventriculography may be necessary to determine proper treatment. Metrizamide, a nonionic water-soluble contrast medium, has been used for myelography and ventriculography in adults and for myelography in children. Eleven children have been ventriculograms using metrizamide with conventional roentgenographic techniques. Diagnostic information was obtained in all but one study. No major complications occurred.

The spleen: development and functional evaluation.

Despite the fact that the spleen has multiple functions, only one has been widely used for evaluation of the organ by imaging techniques (phagocytosis of 99mTc sulfur colloid). The usual splenic uptake of this radiocolloid can by used to determine the size, location, and integrity of the organ. A major use of splenic radiocolloid imaging has been in the study of congenital defects. Thus, eventration of the diaphragm, accessory spleens, splenogonadal fusion, the asplenia and polysplenia syndromes, and the wandering spleen are amenable to study by means of intravenously administered radiocolloid. Interference with the splenic uptake of radiocolloid can be either focal or generalized (as in functional asplenia). Imaging of the spleen has a major role in evaluating suspected trauma of the organ and in following its clinical course. The return of splenic function after splenectomy (splenosis or accessory spleens) can be documented by radionuclide imaging, and likely by hematologic techniques when the volume of tissue is sufficiently large. The detection of intrasplenic lesions is important in tumor staging and as an alerting sign to an ongoing process.

The role of radionuclide studies in pediatric gastrointestinal disorders.

Radionuclide techniques are currently used to fully evaluate many congenital and acquired abnormalities of the gastrointestinal tract of children. Frequently, the anatomic and functional data provided by the nuclear examination are definitive. In the study of many disease entities, tracer techniques have replaced more cumbersome or invasive procedures. Although the radiopharmaceuticals and instrumentation are similar as applied to both children and adults, the uniqueness of children and their disease entities requires special consideration when performing and interpreting their studies. In this review, the principle radionuclide examinations used in the evaluation of pediatric gastrointestinal disorders are detailed and examples are illustrated.

The child with acute leg pain.

Diagnostic imaging is an essential component in the evaluation of a child with acute lower extremity pain or limp. Most, but not all, of the etiologies are traumatic. Frequently, the history and clinical examination are not specific. Radionuclide bone imaging is extremely rewarding in these circumstances. It represents the most useful examination used in evaluating the pathophysiology and full extent of the disorder. This article discusses the clinical presentation, pathophysiology, and characteristic imaging observations in the more common problems associated with hip and/or leg pain.

Spine pain in children.

Spine pain in children as an isolated symptom is infrequently seen in clinical practice. However, as opposed to spine pain in adults, it is accompanied by a relatively higher frequency of pathology. Diagnostic imaging is a necessary follow up to the physical examination and laboratory studies. Standard radiography is usually the initial imaging study. Frequently, however, additional imaging with bone scintigraphy, computed tomography, or magnetic resonance imaging is necessary to add sensitivity and specificity to the clinical presentation. We describe the disease entities, pathophysiology, and imaging characteristics of the varied pathologies responsible for spine pain in children.

Pediatric applications in nuclear oncology.

Imaging procedures (both as they apply to initial diagnosis and assessing the response to therapy) using radionuclides are indispensible in the evaluation of malignant diseases that afflict infants and children. The diagnosis and accurate staging are extremely critical because of continuing improvements in the survival of children with malignant disease when treated with appropriate therapy. The major role of nuclear medicine in this patient group serves to evaluate the skeletal system and the liver and spleen. It is important to keep the pediatric specialist well informed concerning the role that nuclear medicine can play in elucidating many of the clinical problems that this specialist faces.

Radionuclide evaluation in childhood injuries.

Radionuclide techniques serve an important role in evaluating childhood injuries. Frequently, they can be employed as the initial and definitive examination. At times they represent the only modality that will detect specific injuries such as the skeletal system. Familiarity with the advantages and limitations of tracer techniques will insure appropriate management of childhood injuries.

Wire stent for tracheomalacia in a five-year-old girl.

A wire stent was used successfully to treat life-threatening tracheomalacia in a 5-year-old girl. Wire stents placed bronchoscopically are nonobstructing and have the potential for balloon expansion to accommodate growth.

Retroperitoneal and retrofascial abscesses. A review.

The anatomy of retrofascial and retroperitoneal abscesses is not widely understood by orthopaedic surgeons because these abscesses are encountered infrequently and may cause symptoms at their points of extension rather than at their origin. Recent developments in bone-imaging and computed tomographic scanning have made it easier to diagnose and treat these abscesses and to identify their origins. These same diagnostic techniques have also made it easier to distinguish retrofascial from retroperitoneal abscesses. In this paper we define the retrofascial and retroperitoneal spaces, enumerate the possible sources of infection and the pathways of drainage, identify the pelvic spaces where the abscesses collect, and list the peripheral extrapelvic areas where these abscesses cause symptoms. The clinical signs and symptoms of retrofascial and retroperitoneal infection differ from those of osseous infection of the pelvis and spine, the two most common sources of retrofascial infection. The diagnostic value of the various radiographic methods is discussed, the prognoses for various types of abscesses are reported, and approaches to treatment are presented.

Normal high-resolution cerebral 99mTc-HMPAO SPECT scans in symptomatic neonates exposed to cocaine.

Vascular constriction is said to account for a variety of clinical effects of cocaine. High-resolution 99mTc-hexamethylpropylene amine oxime single photon emission computed tomographic (SPECT) scans, which measure cerebral blood flow, were used to determine whether neonatal brain perfusion deficits are present in newborns with confirmed cocaine exposure. Normal, age-appropriate SPECT scans were found in 21 babies. Conventional neuroimaging was also performed when possible. All but one of the 14 magnetic resonance imaging (MRI) scans and one computed tomographic scan were normal. One MRI showed a mild delay in myelination. All but four neonates had behavioral or electroencephalographic abnormalities, and microcephaly was found in five of 21. The normal neonatal SPECT scans contrast with findings in adult cocaine users, which typically report abnormal findings of cerebral hypoperfusion. This study identifies a unique lack of corresponding cerebral vascular pathology in symptomatic neonates. It raises the possibility that many of these children can escape significant ischemic injury.

Hemimegalencephaly: clinical, EEG, neuroimaging, and IMP-SPECT correlation.

Iofetamine-single photon emission computed tomography (IMP-SPECT) was performed on 2 girls (5 1/2 and 6 years of age) with histories of intractable seizures, developmental delay, and unilateral hemiparesis secondary to hemimegalencephaly. Electroencephalography (EEG) revealed frequent focal discharges in 1 patient, while a nearly continuous burst suppression pattern over the malformed hemisphere was recorded in the other. IMP-SPECT demonstrated a good correlation with neuroimaging studies. In spite of the different EEG patterns, which had been proposed to predict contrasting clinical outcomes, both IMP-SPECT scans disclosed a similar decrease in tracer uptake in the malformed hemisphere. These results are consistent with the pattern of decreased tracer uptake found in other interictal studies of focal seizures without cerebral malformations. In view of recent recommendations for hemispherectomy in these patients, we suggest that the IMP-SPECT scan be used to compliment EEG as a method to define the extent of abnormality which may be more relevant to long-term prognosis than EEG alone.

Simplified radioisotope technique for assessing gastroesophageal reflux in children.

There were 125 children with a strong clinical suspicion of gastroesophageal reflux and/or aspiration evaluated with gastroesophageal scintigrams. We found this examination to be more sensitive than the standard barium radiography and highly specific in detecting aspiration of gastric contents. This procedure is simple, safe and more physiologic than other available examinations. However, since gastroesophageal scintigraphy does not delineate anatomic changes as well as barium studies, structural abnormalities of the esophagus and stomach should be evaluated with barium esophagrams and upper GI series.

Technetium-99m biliary imaging in pediatric surgical problems.

The results of scintigraphic imaging of the hepatobiliary system with 99mTc-PIPIDA (IDA derivative p-isopropylacetanilidoiminodiacetic acid) in forty children are reported. 99mTc-PIPIDA imaging is a noninvasive, rapid, safe examination that provides both functional and anatomical information about the hepatobiliary system. Although interpretation is limited by elevated direct serum bilirubin, this agent allows diagnostic information to be obtained with direct serum bilirubin levels up to 8 mg/dl.

Malrotation of bowel: variable patterns with different surgical considerations.

The records of 53 patients with varied roentgenographic patterns of malrotation were reviewed. The patterns were categorized as A-Infantile (Al), A-Adult (Aa), B, C, and D. The differences in form were obvious and each differed clinically, radiographically, and surgically. The differences allowed the development of prognostic insights simply based on the presence and/or position of the ligament of Treitz and the cecum as shown by barium gastrointestinal examination. The literature was reviewed to find supportive or contradictory case material or other data that complemented or devalued the developed system for determining prognosis of patients with varied bowel patterns. The developed prognostic scheme seems to satisfy the requirements of reliability.

Pneumococcal arthritis and osteomyelitis in children.

Five children with pneumococcal bone and joint infections are described. Three of the children were less than one year of age and two had sickle cell disease. All but one had a primary or coincident focus of acute pneumococcal infection elsewhere. In the four children with septic arthritis, osteomyelitis was diagnosed subsequently in bones contiguous to the infected joint. All patients were successfully treated, although one developed permanent joint dysfunction. Although an unusual infection, pneumococcal infection of bones and joints should be sought in the appropriate clinical setting since such infection requires specific surgical therapy and may be associated with significant morbidity.

Cerebral infarction in Hemophilus influenzae type B meningitis.

Over a 5-year period, 8 (4.7%) of the 170 children diagnosed at Milwaukee Children's Hospital as having Hemophilus influenzae type b (HITB) meningitis developed cerebral infarction. Compared with children who did not develop infarcts or with children who developed other neurologic complications, such as subdural effusion, empyema, or meningoencephalitis, these children had significantly higher cerebrospinal fluid (CSF) leukocyte counts on initial lumbar puncture and had a greater likelihood of seizure activity. In seven of eight patients with cerebral infarction, a focal or generalized seizure heralded neurologic findings associated with abnormal radiographic studies. Two of the eight patients died, and two were permanently severely damaged. In the other four patients, there was eventual recovery from gross neurologic deficits. The mortality in patients with HITB meningitis complicated by cerebral infarction (25%) was significantly greater than that in other patients with HITB meningitis (0.6%). The pathophysiology of infarction in patients with bacterial meningitis is uncertain but may in part relate to arteriospasm. Cerebral infarction is a serious, and in the present experience, not uncommon complication of H. influenzae meningitis.

Bacterial epididymo-orchitis in children and adolescents.

Five cases of bacterial epididymo-orchitis are presented. These patients demonstrate three distinct mechanisms of bacterial infection of the intrascrotal structures: epididymo-orchitis as a presentation and a complication of urinary tract infection; epididymo-orchitis associated with sexually transmitted disease; and epididymo-orchitis associated with systemic infection. We recommend urine, urethral, and blood bacterial cultures, in addition to viral serologic studies, as an appropriate evaluation for any patient with epididymo-orchitis.

Atlas of pediatric nuclear cardiology: part II.

Cardiovascular nuclear medicine is an extremely useful clinical tool. The full potential of nuclear techniques in pediatrics has only recently been realized. Depending on the child's problem, one may choose to perform qualitative radionuclide angiography, first-pass studies, gated blood pool studies, myocardial perfusion imaging, particle imaging, or a combination of these studies. The examinations are sensitive, noninvasive, accurate, and available on the clinical level.

Atlas of pediatric nuclear cardiology: part I.

With the recent improvement in instrumentation and tracers, pediatric cardiovascular nuclear medicine has become an extremely useful clinical tool. These noninvasive nuclear examinations provide clinicians with information concerning cardiac physiology and pathophysiology. This review outlines the basic diagnostic nuclear examinations used to evaluate the pediatric cardiovascular system.