Epilepsy in Pediatric Patients-Evaluation of Brain Structures' Volume Using VolBrain Software.

Epilepsy is one of the most frequent serious brain disorders. Approximately 30,000 of the 150,000 children and adolescents who experience unprovoked seizures are diagnosed with epilepsy each year. Magnetic resonance imaging is the method of choice in diagnosing and monitoring patients with this condition. However, one very effective tool using MR images is volBrain software, which automatically generates information about the volume of brain structures. A total of 57 consecutive patients (study group) suffering from epilepsy and 34 healthy patients (control group) who underwent MR examination qualified for the study. Images were then evaluated by volBrain. Results showed atrophy of the brain and particular structures-GM, cerebrum, cerebellum, brainstem, putamen, thalamus, hippocampus and nucleus accumbens volume. Moreover, the statistically significant difference in the volume between the study and the control group was found for brain, lateral ventricle and putamen. A volumetric analysis of the CNS in children with epilepsy confirms a decrease in the volume of brain tissue. A volumetric assessment of brain structures based on MR data has the potential to be a useful diagnostic tool in children with epilepsy and can be implemented in clinical work; however, further studies are necessary to enhance the effectiveness of this software.

Chronic Appendicitis-From Ambiguous Clinical Image to Inconclusive Imaging Studies.

A six-year-old boy visits a general practitioner due to diarrhea and abdominal pain with a moderate fever of up to 39 °C for 2 days. Treatment is initiated; however, the recurrence of abdominal pain is observed. Physical examination of the child at the emergency department reveals abdominal guarding and visible, palpable, painful intestinal loops in the left iliac and hypogastric regions-this is referred to as an 'acute abdomen'. An X-ray shows single levels of air and fluid indicative of bowel obstruction. Ultrasound reveals distended, fluid-filled intestinal loops with diminished motility. The intestinal wall is swollen. Laboratory tests indicate increased inflammatory indices. Contrast-enhanced computed tomography examination of the abdominal cavity and lesser pelvis shows intestinal dilation. The loops were filled with liquid content and numerous collections of gas. The patient is qualified for a laparotomy. An intraoperative diagnosis of perforated gangrenous appendicitis with autoamputation was made. In addition, numerous interloop and pelvic abscesses, excessive adhesions, signs of small intestine micro-perforation, and diffuse peritonitis are found. The patient's condition and laboratory parameters significantly improve during the following days of hospitalization. Despite the implementation of multidirectional, specialized diagnostics in the case of acute abdomen, in everyday practice we still encounter situations where the final diagnosis is made intraoperatively only.

Perianal lesions as an unusual first manifestation of Crohn's disease in pediatric patients - case series.

Primary symptoms of Crohn's disease usually include, among others, abdominal pain and cramping, recurrent diarrhea, fever and weight loss. The aim of this study was to show the effectiveness of ultrasound in the diagnosis and assessment of the extent of perianal complications in Crohn's disease. Five patients (four boys and one girl) aged from 13 to 16 years, with prolonged pain in the perianal area, which worsened when sitting, were admitted to the Department of Pediatric Gastroenterology between 2017 and 2019. Each patient underwent intestinal ultrasound with a high frequency 7-12 MHz linear probe and transperineal ultrasound to assess the anal canal and the surrounding soft tissues. In each case, the echogenicity of the bowel wall was assessed for mural stratification and possible thickening. Anorectal fistulas were detected in all the five patients. Three patients (12 y.o. male, 12 y.o. female and 16 y.o. male) presented with perianal abscesses drained by fistulas. In the first patient the fistula was limited to the perianal soft tissue (22 × 23 mm); in the second patient it was localized within the ischioanal region (40 × 50 mm); and in the third patient (5-6 mm abscess) the fistula was with a hypoechoic fistulous tract reaching the sphincter. All of the patients were eventually diagnosed with Crohn's disease as a result of further clinical workup. Ultrasound examination is a non-invasive, well-tolerated modality for the evaluation of Crohn's disease activity and its possible complications, e.g. fistulas and abscesses. Ultrasound is especially useful in patients who require repeated follow-up investigations.

Nephrocalcinosis in adolescent girl with medullary sponge kidney and mild hemihypertrophy: A case report.

RATIONALE: Medullary sponge kidney (MSK) is a rare congenital abnormality characterized by cystic dilatation of the medullary collecting tubules. The disorder is likely to be complicated by nephrocalcinosis, urolithiasis, tubular dysfunctions, and urinary tract infections. In addition, it may be rarely associated with extrarenal anomalies. PATIENT CONCERN: We present a case of 17-year old girl who was referred for metabolic evaluation of bilateral nephrocalcinosis. Physical examination showed signs of mild, left-sided hemihypertrophy involving the lower limb, buttock, trunk, face, and tongue. The imaging studies of kidneys including intravenous urography and contrast computed tomography showed numerous medullary calcification and a typical picture of MSK-"paint brush"/"bouquet of flowers" appearance of the dilated tubules within the renal medulla. Laboratory evaluation revealed sterile pyuria, hypercalciuria, and hypocitraturia. INTERVENTION: The patient was subsequently treated with potassium citrate, hydrochlorothiazide, low sodium and low oxalate diet accompanied by high fluid intake. OUTCOMES: After a 1-year therapy the normalization of calciuria and citraturia occurred and no progression of nephrocalcinosis was observed. LESSONS: We conclude that MSK should always be considered as a cause of nephrocalcinosis. Since the final diagnosis requires specific imaging techniques, the concomitant extrarenal abnormalities such as hemihypertrophy may facilitate diagnostic decisions.

3D/4D contrast-enhanced urosonography (ceVUS) in children - is it superior to the 2D technique?

BACKGROUND: By now, two-dimensional contrast-enhanced voiding urosonography (ceVUS) has become a well-established method for the diagnosis and treatment monitoring of vesicoureteral reflux in children, particularly after the recent approval for this application in children in the USA and in Europe. The introduction of three-dimensional static (3D) and real-time (4D) techniques with ultrasound contrast agents opens up new diagnostic opportunities for this imaging modality. OBJECTIVE: To analyze whether 3D and 4D ceVUS is a superior technique compared to standard 2D ceVUS in diagnosing vesicoureteral reflux in children. MATERIAL AND METHODS: The study included 150 patients (mean age 3.7 years) who underwent 2D and 3D/4D ceVUS for the diagnosis and grading of vesicoureteral reflux. RESULTS: 2D ceVUS and 3D/4D ceVUS diagnosed the same number of vesicoureteral refluxes, however, there was a statistically significant difference in grading between the two methods. Performing 3D/4D ceVUS resulted in changing the initial grade compared to 2D ceVUS in 19 out of 107 refluxing units (17.76%) diagnosed. The 4D technique enabled a more conspicuous visualization of vesicoureteral reflux than the 3D technique. CONCLUSIONS: 2D ceVUS and 3D/4D ceVUS diagnosed the same number of vesicoureteral refluxes, however, there was a statistically significant difference in grading between the two methods. Thus 3D/4D ceVUS appears at least a valid, if not even a more conspicuous technique compared to 2D ceVUS.

Premature atherosclerosis after treatment for acute lymphoblastic leukemia in childhood.

INTRODUCTION: Late cardiovascular complications are the leading causes of morbidity and mortality in patients treated for common malignancies of childhood. Late cardiotoxicity include increased development of atherosclerosis and atherosclerosis - related diseases. An evaluation of the endothelium can be made based on the measurement of endothelium-derived blood vasoactive factors, such as cytokines and adhesion molecules. Their elevated serum levels may serve as sensitive indicators of early atherosclerotic lesions in high risk patients. Currently, assessment of common carotid intima-media thickness has emerged as one of the more powerful tools for evaluation of subclinical atherosclerosis. The purpose of this study was to compare these parameters between patients after antineoplatic treatment compared to persons not exposed to such factors. MATERIAL AND METHODS: Early progression of atherosclerotic disease was evaluated in 64 survivors treated for Acute Lymphoblastic Leukaemia (ALL) in childhood, and in a control group of 36 healthy volunteers. Blood serum concentrations of selected new biomarkers, indicative of endothelial damage and inflammatory activity, were measured, including intercellular adhesion molecule-1 (sICAM-1), endothelial leukocyte adhesion molecule-1 (E-selectin), thrombomodulin (TM), interleukin 6 (IL-6), and high-sensitivity C-reactive protein (hs-CRP). The common carotid intima-media thickness (IMT) was also assessed via ultrasound examination. RESULTS: Significantly higher blood concentrations of sICAM-1 adhesive molecule (229.3±62.2 ng/mL vs. 199.9 ± 63.3 ng/ mL, p=0.0072) and IL-6 (2.1 ± 2.7 pg/mL vs. 1.9 ± 3.6 pg/mL, p=0.0414) were found in ALL survivors compared with control subjects. Concentration of hs-CRP was also higher in the ALL group: 1.3 ± 2.2 ug/mL vs. 0.6 ± 0.9 ug/mL. This difference was close to statistical significance (p=0.0599). The mean IMT values for right and left carotid arteries were higher in ALL patients after antineoplastic therapy, compared with healthy subjects (IMT-R 0.056±0.008 mm vs. 0.052±0.003 mm; p=0.0021; IMT-L 0.057±0.009 mm vs. 0.052±0.003 mm; p=0.0051). CONCLUSIONS: Survivors of childhood ALL in the examined group demonstrated elevated concentrations of selected new biomarkers and increased IMT values, compared to controls, which may confirm the occurrence of endothelial injuries in blood vessels. This study indicates that subjects treated for childhood malignancy are at a higher risk of prematurely developing atherosclerosis.

Mistakes in the ultrasound diagnostics of the abdominal cavity in pediatrics.

The diagnostics of the abdominal cavity in children, especially in the neonatal-infantile period, requires knowledge in the field of anatomical and physiopathological differences as well as clinical symptomatology and pathology at every stage of the child's development. Errors and mistakes in ultrasound diagnostics of the abdominal cavity in children result from many factors, including lack of experience in examining children and the knowledge concerning most frequent ailments and pathologies as well as the incidence or no changes in the ultrasound image of the abdominal cavity organs. The assessment of the ultrasound image should be always based on clinical data of the patient, information on the past diseases, surgeries and the results of additional examinations and laboratory tests. Particular attention should be paid to the occurrence of congenital diseases and inflammations, which may have varied clinical manifestation - especially in the case of pediatric diagnostics. The variety and non-specific nature of clinical symptoms may also mask the developing neoplastic process. Mistakes in ultrasound diagnostics, especially among the youngest children, may also be caused by technical difficulties related to carrying out the examination. The above situation results from lack of cooperation with the child, who is uneasy, wailing, fails to perform orders, which may lead to overlooking the existing lesion or overinterpreting, e.g. a full stomach or residual stool in the intestines to be a pathology. It is also of high importance to have a good class of the ultrasound equipment and technical knowledge concerning its operation. When performing an ultrasound examination in children, it is necessary to apply a wide range of phased-array, convex and linear heads and appropriate applications, the so-called pediatric software (stomach, kidneys, true pelvis, organs at the surface).

[Maxillary sinus myxoma]. / Sluzak zatoki szczekowej.

Myxoma is a slow growing, benign neoplasm, which pathogenesis still remains disputed. The lesion has well-defined borders but a true capsule is absent. Because of that myxoma can be locally invasive causing bone destruction. A change is mainly observed among persons between 20-30 years of age and is very uncommon in the pediatric population. Most myxomas are observed in myocardium, but rarely may also manifest in the head and neck region. In the paper we describe an unusual case of myxoma of maxillary sinus in a female infant. Diagnostic challenges, treatment, outcome, post-operative follow-up are discussed as well as a review of the literature in order to present many features of this rare pathology.

Closure of the thoracic duct from the left-side access: A case report.

BACKGROUND: We report a 16-year-old patient with a massive left-sided chylothorax after chemotherapy due to mixed germinal tumor of the testis with massive metastases located in the retroperitoneal space and posterior mediastinum. Chemotherapy resolved the metastases in the mediastinum but evoked a huge pleural effusion in the left pleural cavity, requiring surgical intervention.Left-sided access was used. The 5-mm camera and 3 5-mm working ports were inserted. The parietal pleura was incised and the esophagus located and protected. Behind the esophagus, the thoracic duct and concomitant tissue were clipped with titanium clips, and additionally, thrombin glue was used. Stopping of the lymph leakage was observed during surgery. A local argon pleurodesis was used to finish the procedure. The thoracic tube was removed on the third postoperative day. CONCLUSION: Left-side access may be a good alternative in the left-sided chylothorax, but the crucial points are location and protection of the esophagus during the procedure, which is also the landmark that allows for locating the thoracic duct.

Color Doppler dynamic tissue perfusion measurement: a novel tool in the assessment of renal parenchymal perfusion in children with vesicoureteral reflux.

INTRODUCTION: Vesicoureteral reflux (VUR) occurs in 20-50% of children suffering from recurrent urinary tract infections (UTIs) and is associated with an increased risk of renal scarring and impaired renal function. Early detection of renal perfusion deterioration would allow for the implementation of more aggressive treatment and potentially prevent further damage to the renal parenchyma. The aim of the study was to assess renal parenchymal perfusions in children with recurrent UTIs with and without coexisting VUR, and compare the findings with the results of healthy patients. MATERIAL AND METHODS: Color Doppler sonographic dynamic renal parenchymal perfusion measurements were performed with PixelFlux (Chameleon-Software, Germany) software in 77 children with recurrent UTIs and coexisting VUR and in 30 children with UTIs without VUR. The findings were compared with the results of 53 healthy children. RESULTS: Cortical parenchymal perfusion of children suffering from UTIs and VUR was significantly reduced when compared to the control group. Statistically significant differences (p < 0.05) were found in all perfusion parameters (i.e. mean velocity (v mix ), mean perfused area (A mix ), mean perfusion intensity (I mix ), tissue pulsatility index (TPI), and tissue resistance index (TRI)) between the control group and children suffering from UTIs and VUR, particularly VUR grades III and IV. There were no significant differences between the UTI group and the control group. No differences were found between the controls and VUR grade II. CONCLUSIONS: Renal parenchymal perfusion decreases significantly with higher grades of VUR.

The Estimation of Intima-Media Thickness and Cardiovascular Risk Factors in Young Survivors of Childhood Cancer.

Cancer treatment in childhood is thought to accelerate the development of atherosclerosis, leading to significant cardiovascular complications and, ultimately, increasing cardiovascular mortality in childhood cancer survivors, which explains the need to assess vascular status in this group. The purpose of this paper was to assess early atherosclerotic lesions based on the analysis of intima-media thickness (IMT) of the common carotid artery, as well as to analyze cardiovascular risk factors in young childhood cancer survivors. The analysis of 158 patients aged 6 to29 years, with a history of previous cancer treatment for different childhood malignancies, revealed a statistically significant difference in IMT between them and 66 age-matched healthy controls. The observed higher IMT scores in childhood cancer survivors may be indicative of premature atherosclerosis. The actual scores were 0.056±0.007 versus 0.052±0.003 (P=0.0001) as a mean score for both carotid arteries in the study group and controls, respectively. We did not observe significant differences in IMT between cancer survivors treated with chemotherapy only versus those treated with chemotherapy and radiotherapy. Similar to the general population, childhood cancer survivors are affected by different cardiovascular risk factors. These factors may enhance the direct cardiotoxicity of cancer treatment, leading to symptomatic incidents in further life, which emphasizes the need of early prevention and/or treatment in this subpopulation.

Two-dimensional (2D), three-dimensional static (3D) and real-time (4D) contrast enhanced voiding urosonography (ceVUS) versus voiding cystourethrography (VCUG) in children with vesicoureteral reflux.

BACKGROUND: Two-dimensional (2DUS) contrast enhanced voiding urosonography has been used in the diagnosis and treatment monitoring of the vesicoureteral reflux in children for over 15 years. The opportunity of performing this examination with the use of three-dimensional static (3DUS) and real-time (4DUS) techniques opens up new diagnostic horizons. OBJECTIVE: To analyze if 3DUS/4DUS bring additional information leading to an increased detection rate or change in the grading of reflux compared to 2DUS and voiding cystouretrography. MATERIAL AND METHODS: We evaluated 69 patients (mean 4.1 years) who underwent 2DUS/3DUS/4DUS contrast enhanced voiding urosonography (ceVUS) and voiding cystourethrography (VCUG) for the diagnosis and grading of vesicoureteral reflux. RESULTS: 2DUS and 3DUS/4DUS urosonography diagnosed 10 more refluxes (7.25%) than cystourethrography and in 3 refluxes (2.17%) detected a higher grade. In 9 refluxes (6.52%) 3DUS/4DUS urosonography and cystourethrography diagnosed a higher grade than 2DUS. There was a statistically significant difference between cystourethrography and 3DUS/4DUS urosonography when the number of detected refluxes and differences in grading were compared. 4DUS enabled a better visualization of reflux than 3DUS. CONCLUSIONS: 3DUS/4DUS techniques bring additional information leading to a change in reflux grading compared to 2DUS and a detect higher number of refluxes compared to cystourethrography.

Intraoperative contrast-enhanced urosonography during endoscopic treatment of vesicoureteral reflux in children.

BACKGROUND: There are many controversies surrounding the effectiveness of endoscopic treatment of vesicouretheral reflux (VUR) in children, thus it is of highest priority to analyze factors influencing the outcome of therapy and to search for new methods that would increase the success rate and reduce the number of reinjections. OBJECTIVE: The aim of the study was to analyze whether intraoperative contrast-enhanced urosonography (ce-US) may increase the effectiveness of endoscopic anti-reflux therapy. MATERIALS AND METHODS: Intraoperative contrast-enhanced urosonography (ce-US) with SonoVue® was performed in 17 patients (25 ureteral units) undergoing endoscopic treatment of VUR. Ce-US was performed in the operating room before the procedure and after injection of the bulking material. When VUR persisted, the operator repeated the injection, which was followed by ce-US. The results were compared with those obtained from a control group (15 patients; 22 ureteral units). RESULTS: A repeat injection during a single endoscopic treatment was required in 24% of cases. The overall success rate confirmed at 6-12 months' follow-ups was 84%. The success rate was significantly higher in comparison to the control group (success: 64%). CONCLUSION: Intraoperative ce-US performed during endoscopic treatment of VUR enables immediate monitoring of outcome and provides the opportunity for repeat injection during the same procedure, thus increasing the efficacy of the procedure and reducing the number of reinjections.

Testicular adrenal rest tumors in boys with congenital adrenal hyperplasia: 3D US and elastography--do we get more information for diagnosis and monitoring?

BACKGROUND: Testicular adrenal rest tumors (TART) are the nodular testicular lesions deriving from the adrenal remnant tissue reported in boys and men with congenital adrenal hyperplasia. Until now, the diagnostics of TART have been based on a combination of clinical features, imaging methods (primarily two dimensional ultrasound--2D US), response of the foci to glycocorticosteroid (GCS) therapy and exclusion of the neoplastic process. Application of 2D US supplies however a limited range of information about the volume, demarcation, structure and vascularization of the lesions. OBJECTIVE: To define whether the use of 3D US, power Doppler and elastography changes the algorithm of the diagnostics and monitoring or treatment of TART. MATERIAL AND METHODS: In this study, modern ultrasound techniques such as 3D US and elastography were introduced in two boys with TART. RESULTS: The 3D power Doppler option gives the opportunity for accurate assessment of the volume of testes and adrenal tissue foci and their vascularization. Sonographic elastography allows the assessment of stiffness of adrenal tissue areas compared to normal testis parenchyma. CONCLUSION: The use of these modern techniques enables more adequate and advanced diagnostics, and more precise monitoring of the effects of treatment in patients with TART.

Ultrasound presentation of abdominal non-Hodgkin lymphomas in pediatric patients.

INTRODUCTION: Burkitt's lymphoma accounts for approximately 25% of lymphomas diagnosed in children of developmental age. The tumor is localized mainly in the intestine (usually in the ileocecal region), mesenteric lymph nodes and extraperitoneal space. The clinical symptoms are non-specific and include: abdominal pain, vomiting, gastrointestinal bleeding, and acute abdomen suggesting appendicitis or intestinal intussusception. On ultrasound examination, Burkitt's lymphoma may manifest itself in various ways, depending on the origin of the lesion. AIM: The aim of this paper was to review the ultrasound manifestation of abdominal Burkitt's lymphoma in children. MATERIAL AND METHODS: The analysis included 15 pediatric patients with Burkitt's non-Hodgkin lymphoma in the abdominal cavity. The mean age of the patients was 9.5. Abdominal and gastrointestinal ultrasound examinations were conducted using a Siemens scanner with a convex transducer of 3.5-5 MHz and linear array transducer of L4 - 7.5 MHz. RESULTS: Ultrasound examinations conducted in the group of 15 patients revealed pathological masses localized in the gastric wall in 3 patients (20%), in the ileocecal region in 10 patients (67%) and a disseminated process in 2 patients (13%). In 12 patients with a diagnosed Burkitt's non-Hodgkin lymphoma in an extragastric localization, differences in the morphology of the lesions were observed. CONCLUSIONS: The clinical and ultrasound picture of abdominal Burkitt's lymphoma in children is variable. A careful ultrasound assessment of all abdominal organs conducted with the use of convex and linear probes increases the chances of establishing an adequate diagnosis.

High frequency ultrasound diagnostics of right lower quadrant abdominal pain in children.

In our study we tried to assess the usefulness of high frequency ultrasound examinations in the diagnostics of right lower quadrant abdominal pain, focusing on the differential diagnosis of appendicitis. Ultrasound examinations were performed on 152 patients aged 1 to 19 with abdominal pain. All the children underwent standard abdominal ultrasound examination with B mode of abdominal parenchymal organs as well as the evaluation of the intestines with the linear transducer of changeable frequency with the possibility of creating sector format. The tissue harmoning imaging (THI), Power and Colour Doppler modes were also applied in the examinations. As a result, 21 (13.8%) of 152 examined patients did not demonstrate any abnormalities in ultrasound examination. In the group the appendix was not visible. In the other 131 (86.2%) patients we observed a number of pathologies such as following: in 96 (73.3%) patients visible appendix, in 8 (6.1%) enlarged mesenteric lymph nodes, in 6 (4.6%) pathological broadening of the distal ileum wall, in 6 (3.2%) pathological broadening of the caecum wall and others. All these symptoms might be treated as indirect symptoms of appendicitis. In conclusion, we would like to state that high frequency ultrasound examination is very useful in the diagnostics of appendicitis.

Solid tumours of perimeningeal region in children--diagnostic and therapeutic difficulties.

Thirteen patients, aged 2-17 years, were treated because of primary solid tumours of head and neck location at the Department of Children Hematology and Oncology in Lublin. The authors analyzed clinical symptoms before diagnosis and the duration of these symptoms as well as the kind of tumours. In all cases the tumour was diagnosed on histopathological examination: soft tissue sarcomas--9 children, lymphoepithelioma--4 ones. The prognosis and treatment were estimated.

The application of ultrasound contrast, 3D imaging and tissue harmonic imaging in the differential diagnosis of lymph nodes enlargement in children.

The application of Power Doppler mode examination introduced the assessment of vascularisation and measurement of blood flow parameters in lymph node's vessels as a differentiating criterion of benign and malignant lymphadenopathy. However, those criteria appeared insufficient in evaluation of the malignancy grade of enlarged lymph nodes, especially in the cases of lymph nodes with invisible or scantly visible vascularisation in Power Doppler mode. Introducing contrast media in ultrasonographic examinations enabling intensification of the Doppler signal even by 20 dB creates the hope of increasing diagnostic efficacy of ultrasonography in evaluation of vascularisation in lymph nodes enlargement. The purpose of the study was to define the usefulness of ultrasonographic contrast media (Levovist), 3D presentation and harmonic imaging in differential diagnosis of lymph nodes enlargement in children. 32 children with cervical lymph nodes enlargement underwent examination with ultrasonography. In the examinations, Levovist by Schering was used in concentration 300, the amount depending on patient's body mass. The analysis of results obtained in the study revealed that application of contrast media enables better visualisation of lymph node vascularisation. Localisation of the vessels which were not shown in conventional Doppler mode enables visualisation of the vessel architecture in the lymph node and better defining of vascularisation pattern. Application of the new methods of THI and 3D imaging and contrast media in Power Doppler examinations increases the diagnostic efficacy of ultrasonography in differentiating lymph nodes alternations.