Aortopulmonary window: a rare congenital heart disease.

We report the case of a 3,5 month-old infant presented at cardiology consultation of our institution for investigation of a heart murmur associated with failure to thrive and respiratory distress. Echocardiogram showed dilatation of left heart cavities, patent foramen ovale, small muscular ventricular septal defect and pulmonary hypertension. Angio-CT was performed on a 64-slice CT to better characterize the congenital heart disease. Aortopulmonary window was diagnosed and surgically corrected. Patient evolution was good with discharge 10 days after surgery. The authors review the literature and stress the importance of angio-CT in pre-operative evaluation.

Virtual autopsy by computed tomographic angiography of the fetal heart: a feasibility study.

OBJECTIVE: To determine the feasibility of postmortem computed tomographic (pm-CT) angiography for fetal heart evaluation. METHODS: Following termination of pregnancy (TOP) or intrauterine fetal death (IUFD) beyond 18 weeks' gestation, 33 fetuses were examined by pm-CT; in eight contrast medium was injected through the umbilical cord and in 25 contrast medium was injected directly into the heart. Logistic regression analysis was used to investigate the effect on the ability to visualize cardiac structures on pm-CT angiography of gestational age at TOP or delivery following IUFD, the time delay between fetal death and examination, the technique used for contrast-medium injection, the presence of cardiac abnormalities and whether or not there was IUFD. The diagnostic accuracy of pm-CT angiography for the evaluation of fetal cardiac structures was also evaluated. RESULTS: Cardiac anatomy including heart situs, the four-chamber view and great vessels could be visualized on pm-CT angiography in 29 out of 33 fetuses (87.9%). Logistic regression analysis showed that the ability to visualize cardiac structures on pm-CT angiography was positively correlated only with contrast medium injected directly into the heart. Twenty-five out of the 33 fetuses underwent conventional autopsy. There were five cases with suspected major cardiac abnormality at prenatal ultrasound and one with a minor cardiac abnormality. In one of these cases, severe leakage into the pleural cavity did not allow for visualization of any heart structure on pm-CT angiography and in another invasive autopsy was declined. In two of the remaining four cases, the findings on pm-CT angiography and invasive autopsy were in agreement, while in two a ventricular septal defect was found on invasive autopsy but not on pm-CT. None of the 27 cases with normal hearts was falsely classified as abnormal using pm-CT angiography. CONCLUSION: Pm-CT angiography by direct injection into the heart seems to be a feasible method for its evaluation. The extent to which such a technique could be used for the evaluation of congenital heart disease as an alternative to classical postmortem autopsy remains to be determined.

Magnetic resonance imaging in the normal fetal heart and in congenital heart disease.

OBJECTIVE: To evaluate prospectively the feasibility of magnetic resonance imaging (MRI) for assessment of the fetal heart for congenital heart disease (CHD). METHODS: This was a cross-sectional study, including 66 fetuses with a normal heart and 40 with CHD. The fetal heart was examined on MRI using axial steady-state free precession (SSFP) sequences. Regression analysis was used to investigate the effect on the ability to visualize cardiac anatomy of gestational age at examination, maternal body mass index, presence of fetal cardiac abnormality, fetal movements, fetal lie and twinning. The sensitivity and specificity of detecting cardiac defects were calculated. RESULTS: The four-chamber view was visualized in 98.1% of fetuses. The sensitivity of detecting a cardiac defect on the four-chamber view was 88% and the specificity 96%. The ability to visualize the left and right outflow tracts was only influenced by the presence of fetal movements: for the left outflow tract 94.4 vs. 50.0% visualization and for the right outflow tract 92.6 vs. 53.8% visualization without and with fetal movements, respectively. The sensitivity of detecting a cardiac defect of the left outflow tract was 63% and the specificity 100%, while sensitivity and specificity were 59 and 97%, respectively, for the right outflow tract. CONCLUSIONS: Despite the use of SSFP sequences, MRI in the fetal heart remains of limited value. It can only be used as a second-line approach for abnormalities of the four-chamber view suspected at prenatal ultrasound.

Tolosa-Hunt syndrome in children.

We report a case of Tolosa-Hunt syndrome in a 4-year-old girl. Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) revealed a left cavernous sinus involvement with internal carotid artery occlusion. Clinical signs included left ophthalmoplegia, convulsions and right hemiplegia. Etiopathogenesis of this syndrome is unclear but as in our case, response to corticosteroid therapy is spectacular and avoids unnecessary invasive diagnostic procedures. We underline the importance of cross-sectional imaging in the diagnostic approach. Several other diseases including tumors, vascular lesions and infections can have a similar clinical and/or imaging presentation. However, closely monitored evolution on imaging proves to be decisive in the establishment of final diagnosis of this syndrome.

Unusual clinical manifestation of lymphangiomatosis.

A 6-year- old boy presented with disseminated intravascular coagulation and was diagnosed with lymphangiomatosis. Disseminated intravascular coagulation develops in a minority of cases. Bone lesions were present on his left shoulder. The authors discuss the diagnostic findings and medical management.

Osteoprotegerin and progression of coronary and aortic calcifications in chronic kidney disease.

Vascular calcifications (VCs) are important predictors of cardiovascular mortality in patients with chronic kidney disease (CKD). We have shown previously that osteoprotegerin (OPG), a potential early biomarker for VC, was an independent predictor of mortality in CKD patients. The aim of our study was to follow longitudinally coronary and aortic VCs. VCs were measured using Siemens 16 detector CT in a group of predialysis and hemodialyzed patients before and after a follow-up of 4 years. Some of these patients were transplanted in the meantime. Renal function, calcium, phosphate, iPTH, hs-CRP (high sensitive protein C reactive), and OPG serum levels were also compared. VCs progressed in predialysis, hemodialyzed, and transplanted patients but the progression was not the same in all arterial beds. A progression of coronary calcifications was observed in predialysis and transplanted patients, while aortic calcifications worsened significantly only in hemodialyzed patients. OPG serum levels and hs-CRP were significantly lower among transplanted patients. We concluded that VC depends on the severity of the kidney disease. Transplanted patients are not protected from VC, yet their OPG serum levels were significantly lower, suggesting that there is no link between between OPG levels and severity of VC. Longer follow-up of these patients would be necessary to assess whether a decline in OPG correlates with better survival.

Late diagnosis of extra-pulmonary tuberculosis leads to irreversible kidney failure in a non-immunocompromised patient.

We report a case of extra pulmonary tuberculosis with multiple localizations including bone and kidney in a 21-year-old Pakistani immigrant living in Belgium. Late diagnosis of tuberculosis may lead to end stage renal disease and dialysis. Countries with low prevalence of tuberculosis should be vigilant towards high risk groups for tuberculosis because this preventable and curable disease may lead to devastating complications when diagnosed late.

[Acute myocardial infarction and MRI: a comparison of infarct size by MRI and peak creatine kinase after a first episode]. / Infarctus du myocarde et IRM: étude de la masse nécrosée par rapport au pic de créatine kinase après un premier infarctus.

AIM: To compare the assessment of infarct size using MRI and peak CK value. POPULATION AND METHODS: 16 patients presenting with a first MI and seriall measurement of CK underwent gadolinium-enhanced MRI. RESULTS: A significant correlation was observed between both estimates of infarct size (r=0.56, p=0.0025). In addition, an inverse correlation was found between residual viability and peak CK (r=-0.51; p=0.043). CONCLUSION: After a first episode of MI, infarct size estimate by MRI correlates with that determined by peak CK measurement.

[Imaging in paediatric epilepsy]. / Imagerie de l'épilepsie chez l'enfant.

Epilepsy is a chronic disease, often with an onset during childhood and characterized by spontaneous and recurrent seizures. It concerns 0.5-1% of children under 16 years of age. A classification proposed by the International League Against Epilepsy (ILEA) in 2001 takes into account recent genetic factors involved in epilepsy and attenuates the sharp demarcation between generalized and partial seizures. This classification tends to define whether imaging is indicated or not. Imaging is useless in simple cases of fits associated with hyperthermia and in benign idiopathic epilepsy. It is debated if it is a first episode of epilepsy without a particular context and no neurological signs. In all other cases of epilepsy in children, imaging is indicated. In descending order of frequency the possible causes include malformations (as abnormal gyral development and phakomatoses), hypoxic-ischemic lesions, non-accidental injuries, infections, metabolic diseases and tumors. Being much more sensitive than computed tomography (CT), magnetic resonance imaging (MRI) is the technique of choice to identify an underlying cause in symptomatic epilepsy. Clinical data are mandatory in order to direct a proper MRI investigation. The recently developed diffusion-weighted sequence is particularly useful in the acute phase of certain events such as hypoxia-ischemia, trauma and metabolic disease. CT scan is used in emergency situations and also as a complement to MRI for example to identify calcified lesions. In this way, imaging contributes to establish the nature and define the extension of epileptogenic lesions, thereby guiding therapeutic management. MRI also allows follow-up of the consequences of repeated seizures (such as mesial temporal sclerosis and selective neuronal necrosis) on the cerebral parenchyma and plays a role in the establishment of a prognosis.

Skull base chordoma: CT and MRI features.

We report the case of a 10-year-old boy who presented an intracranial chordoma and we stress the importance of sectional imaging to approach the diagnosis. Clinical presentation is related to local invasion. Lesion of the body of the clivus can extend ventrally or dorsally and cause cranial nerve palsies, brain stem compression or hydrocephalus. Pathologically, they form soft, grey masses that are histologically benign but locally invasive and destructive. Both computed tomography (CT) and magnetic resonance (MR) imaging clearly depict the lesion. CT better demonstrates bone destruction and intralesional calcifications. In our case, MR was performed first and showed all the classical signs of skull base chordoma. CT provided complementary information about bone destruction which are also usual in this type of lesion. Major differential diagnoses of the chordoma in the clivus are the other central skull base masses. Biopsy and histology make the diagnosis. Usually treatment consists in surgery and radiotherapy but more recently proton beam therapy is used and seems to yield better results.

[Headache in childhood: which diagnostic imaging strategies?]. / Céphalées chez l'enfant: quand et quelle imagerie?

There are various causes of headaches in children. The majority of cases are considered as primary and include migraine and tension headaches. Headaches secondary to an underlying pathology are much less frequent. The aim of imaging will be to depict lesions that can benefit from specific therapy and hence improve life quality and expectancy of the affected child. In case of secondary headaches, imaging will have to precise the diagnosis, which is based mainly upon history of the disease and clinical findings. These findings are important to the radiologist as they will help to choose the more adequate technique between CT scan and MRI. This choice is based upon the presumed diagnoses, degree of emergency and availability of the technique. Knowledge of the differential diagnoses influences the way to perform the examination itself (choice of slice thickness, plane of imaging, MR sequences, need for an MR angiogram or injection of contrast medium...). In our opinion, dedicated MR imaging is the technique of choice to investigate secondary headaches in children given its superior sensitivity in depicting certain tumors (glioma of the pons, posterior fossa tumors...), intracranial hypotension, Chiari I malformation, lesions of the hypothalamo-hypophyseal axis etc...

[Atypical presentation of an intestinal duplication in a three month old child]. / Présentation atypique d'une duplication intestinale chez un enfant de trois mois.

Intestinal duplication is an uncommon congenital anomaly that often is diagnosed during childhood. Ultrasound diagnosis is based on the presence of a characteristic double-walled cystic mass. We report a case of duplication in a three Month old child presenting with small bowel obstruction. This case is unusual due to the presence of calcifications that are uncommon in intestinal duplication.

An unusual case of herniation of small bowel through an iatrogenic defect of the falciform ligament.

Internal herniation through a congenital defect in the falciform ligament is extremely rare. We report an unusual observation of small bowel obstruction through an iatrogenic defect of the falciform ligament. Prompt diagnosis was made by helical CT, permitting a rapid surgical procedure to preserve the viability of the obstructed segment.

CT and 99mTc-DMSA scintigraphy in adult acute pyelonephritis: a comparative study.

PURPOSE: The aim of this prospective study was to evaluate the relative value of CT and (99m)Tc-DMSA scintigraphy in the diagnosis of acute pyelonephritis (APN) in adult patients suspected of having urinary tract infection. METHOD: The study was conducted in 36 patients presenting with symptoms suggestive of urinary tract infection. Plain B-mode sonography, CT with contrast medium, and (99m)Tc-DMSA scintigraphy of the kidneys were performed in all patients. Both CT and (99m)Tc-DMSA scintigraphy were performed within 72 h after admission. RESULTS: Twelve patients with clinical and biological signs of urinary tract infection had no CT or (99m)Tc-DMSA scintigraphy abnormalities. Among these patients, lower urinary tract infection was found in 10 patients and 2 patients had ureteral obstruction. In the 24 remaining patients, the diagnosis of APN was made. Among these patients, a correlation was found between CT and (99m)Tc-DMSA scintigraphy in 11 cases. In two cases, both examinations were normal, and in nine cases, both were abnormal. In 11 cases of the 13 remaining patients, abnormal CT was found with normal (99m)Tc-DMSA scintigraphy, whereas the 2 last cases had normal CT and abnormal (99m)Tc-DMSA scintigraphy results. In two cases, bilateral lesions found on CT manifested as unilateral abnormalities on (99m)Tc-DMSA scintigraphy images. CONCLUSION: The diagnosis of APN in adult patients is based on clinical presentation and biological findings. Few studies have compared (99m)Tc-DMSA scintigraphy with CT in the detection of parenchymal involvement in APN. We conclude that CT is more accurate than (99m)Tc-DMSA scintigraphy in the detection of APN lesions in adult patients.