Stroke Recurrence in Children with Vertebral Artery Dissecting Aneurysm.

BACKGROUND AND PURPOSE: Pediatric vertebral artery dissecting aneurysm is a subtype of vertebral artery dissection that can be challenging to diagnose and may be associated with stroke recurrence. This study examines the presenting features, clinical outcomes, and recurrence risk in a cohort of children with vertebral artery dissection, comparing those with aneurysms with those without. MATERIALS AND METHODS: The medical records of children evaluated for vertebral artery dissection were retrospectively reviewed for neurologic presentation, treatment, stroke recurrence, and angiographic appearance of dissection. Cohort patients were categorized into 2 groups based on the presence or absence of a vertebral artery dissecting aneurysm and compared via the Fisher exact test, Student t test, and log-rank analyses. P < .05 was deemed statistically significant. RESULTS: Thirty-two patients met the inclusion criteria, including 13 with vertebral artery dissecting aneurysms. Five cases of vertebral artery dissecting aneurysm were missed on the initial evaluation and diagnosed retrospectively. All patients received antiplatelet or anticoagulation therapy at the time of diagnosis. Children in the vertebral artery dissecting aneurysm group were more likely to present with stroke (P = .059), present at a younger age (P < .001), and have recurrent stroke (P < .001) compared with the group of children with vertebral artery dissection without an aneurysm. After surgery, no patients with vertebral artery dissecting aneurysm experienced recurrent stroke (P = .02). CONCLUSIONS: Vertebral artery dissecting aneurysm is often missed on the initial diagnostic evaluation of children presenting with stroke. In children with vertebral artery dissection, the presence of an aneurysm is associated with stroke presentation at a younger age and stroke recurrence.

Multicenter randomized controlled trial on Duration of Therapy for Thrombosis in Children and Young Adults (the Kids-DOTT trial): pilot/feasibility phase findings.

BACKGROUND: Randomized controlled trials (RCTs) on pediatric venous thromboembolism (VTE) treatment have been challenged by unsubstantiated design assumptions and/or poor accrual. Pilot/feasibility (P/F) studies are critical to future RCT success. METHODS: The Kids-DOTT trial is a multicenter RCT investigating non-inferiority of a 6-week (shortened) versus 3-month (conventional) duration of anticoagulation in patients aged < 21 years with provoked venous thrombosis. Primary efficacy and safety endpoints are symptomatic recurrent VTE at 1 year and anticoagulant-related, clinically relevant bleeding. In the P/F phase, 100 participants were enrolled in an open, blinded-endpoint, parallel-cohort RCT design. RESULTS: No eligibility violations or randomization errors occurred. Of the enrolled patients, 69% were randomized, 3% missed the randomization window, and 28% were followed in prespecified observational cohorts for completely occlusive thrombosis or persistent antiphospholipid antibodies. Retention at 1 year was 82%. Interobserver agreement between local and blinded central determination of venous occlusion by imaging at 6 weeks after diagnosis was strong (k-statistic = 0.75; 95% confidence interval [CI] 0.48-1.0). The primary efficacy and safety event rates were 3.3% (95% CI 0.3-11.5%) and 1.4% (95% CI 0.03-7.4%). CONCLUSIONS: The P/F phase of the Kids-DOTT trial has demonstrated the validity of vascular imaging findings of occlusion as a randomization criterion, and defined randomization, retention and endpoint rates to inform the fully powered RCT.

Diffuse, retroperitoneal mesenteric and intrahepatic periportal plexiform neurofibroma in a 5-year-old boy.

We present a case of plexiform neurofibroma involving the retroperitoneum, mesentery, and liver in a 5-year-old boy who underwent evaluation for extent of a palpable left neck mass. The mass had intrathoracic extension with great vessel encasement and extension into the abdomen. Abdominal CT revealed a diffuse low-attenuation non-enhancing mass encasing the retroperitoneal vessels with serpiginous extension into the liver along the portal vein. This spread pattern of plexiform neurofibroma is an unusual manifestation of neurofibromatosis in a young child.

Benign pneumatosis in children.

BACKGROUND: In pediatrics, pneumatosis intestinalis (PI) is usually due to necrotizing enterocolitis in premature newborns. Beyond infancy, PI is uncommon. "Benign pneumatosis" is PI in patients with few or no symptoms that resolves with conservative management. OBJECTIVE: Our goal was to better characterize benign PI in children. Our investigation focused on identifying underlying risk factors, symptoms at time of diagnosis, management and outcome. MATERIALS AND METHODS: Available medical records and radiographs of children with pneumatosis intestinalis from 1990 to 1998 were reviewed for underlying conditions, symptoms at time of radiographs, management and outcome. RESULTS: Thirty-seven children (mean age 4 years) were included. Thirty-two children had identifiable risk factors. Twenty-five children were immunocompromised by their underlying conditions or therapeutic regimen. Thirty-five children were managed conservatively with resolution of PI. Two patients, however, required surgery and one patient died. CONCLUSION: Benign pneumatosis does occur in children. The majority have underlying risk factors, most commonly related to immunosuppression. Clinical deterioration is the most useful indicator for surgical intervention. In most patients PI resolves with conservative management.

Parietal pseudofracture and spontaneous intracranial hemorrhage suggesting nonaccidental trauma: report of 2 cases.

Massive intracranial hemorrhage, no history of trauma and radiographic findings that were initially interpreted as linear parietal fractures raised the possibility of nonaccidental trauma in 2 infants. Both had severe coagulopathy, 1 due to hemorrhagic disease of the newborn (vitamin K deficiency) and the other due to disseminated herpes simplex virus infection. Both infants died. At autopsy, the parietal bone abnormalities were not fractures, but proved to be an anomalous suture in 1 and a connective tissue fissure in the other.

Small intestinal obstruction by remnants of the omphalomesenteric duct: findings on contrast enema.

OBJECTIVE: We reviewed the contrast enema examinations and medical records of six patients with small intestinal obstruction due to omphalomesenteric duct remnant to evaluate for characteristic imaging findings. RESULTS: In five out of the six patients the point of obstruction was demonstrated on the enema; in three patients, the characteristic "beak" of a volvulus was seen, either in the terminal ileum or cecum. In three patients, there was medial deviation of the cecum. CONCLUSION: The characteristic radiographic features of volvulus at the cecum or terminal ileum and medial deviation of the cecum should suggest persistence of an omphalomesenteric duct remnant as the etiology of obstruction in a child less than 2 years of age. The appearance of omphalomesenteric duct remnant obstruction on enema examination, though not specific, is characteristic and should be familiar to pediatric radiologists.

Impact of sonography on the diagnosis and treatment of acute lower abdominal pain in children and young adults.

OBJECTIVE: Our purpose was to evaluate the impact of sonographic data on clinical physicians' diagnostic confidence and their treatment of children and young adults with acute lower abdominal pain. SUBJECTS AND METHODS: Senior surgical and emergency department staff completed questionnaires before and after abdominal sonography was performed on 94 of 101 consecutive children and young adults with acute lower abdominal pain, pelvic pain, or both. Physicians who were unaware of sonographic data stated the most likely diagnosis and their level of confidence in their diagnosis and then formulated clinical plans. After they were given sonographic data, physicians again stated the most likely diagnosis, estimated their level of confidence, and formulated revised treatment plans. RESULTS: Sonographic data resulted in revised clinical diagnoses in 52% of the patients. Overall, the gain in diagnostic confidence for the entire study population was 33% (95% confidence interval [CI], 27-38%; p < .0001). The impact on the physicians' confidence was greater in those children and young adults whose diagnoses changed after sonography (mean increase in physicians' confidence, 48.3%; 95% CI, 47-75%). In patients whose diagnoses were not changed after sonography, the mean increase in physicians' confidence was 17.6% (95% CI, 11-24%; p < .0001 [analysis of variance]). Physicians used sonographic data to change initial treatment plans in 43 patients (46%). Of these 43 patients, a lower intensity of care was given to 30 patients (70%) and a higher intensity to 13 patients (30%). CONCLUSION: Sonographic data frequently changed initial clinical diagnoses, thus increasing diagnostic confidence and changing clinical treatment decisions in the setting of acute lower abdominal pain in children and young adults.

Bronchopulmonary foregut malformation mimicking neuroblastoma.

We report the case of a patient with an unusual, complex bronchopulmonary foregut malformation. The malformation included an extralobar sequestration, an esophageal duplication cyst, and a gastric duplication cyst. Postnatal imaging suggested a fetal adrenal neuroblastoma.