[Ultrasound of the neonatal hip: initial evaluation and follow-up]. / Échographie de la hanche néonatale : bilan initial et suivi thérapeutique.

Developmental dysplasia of the hip can arise in utero due to a dislocating posture, sometimes associated with predisposing genetic factors. The ideal time for diagnosis is during the neonatal period and adequate screening procedures must be in place. Indeed, the plasticity of hyaline cartilage and fibrocartilage combined with the growth potential at this age nearly always result in rapid complete resolution of the deformity. Ultrasound, when indicated, is the best imaging modality for diagnostic confirmation. It allows evaluation of the osteocartilaginous structures, joint space and soft tissues. Ultrasound provides the clinician with a reliable morphologic and dynamic evaluation tool improving the diagnostic accuracy and guiding orthopedic treatment. Our experience, dating back to 1985, is based on a population imaged between 2007 and 2009. From a total of 2480 neonates screened because of abnormal finding or risk factors, we identified 257 cases of dislocation (10%) in 191 neonates : 14 cases of nonreducible dislocation (10 neonates), 30 cases of reducible hip dislocation (24 neonates), 97 cases of dislocatable hip (73 neonates) and 116 cases of subluxable hip (84 neonates). Clinical and sonographic follow-up demonstrated therapeutic success in 237 cases (93%) and failure in 20 cases (one case of subluxable hip, two cases of dislocatable hip, three cases of dislocated hip, 14 cases of nonreducible hip dislocation). Imaging follow-up (6 to 24 months) showed asymmetry in the size of the proximal femoral epiphyses in 20 cases (with resolution in 10 cases), three cases of dysplasia and one case of post-reduction osteochondritis.

[MRI of fetal GI tract]. / IRM du tube digestif foetal.

The fetal diagnosis of GI tract abnormalities may be improved by the use of MRI that is able to visualize the normal bowel, may characterize the nature and location of gastrointestinal abnormalities, detect severe malformations, demonstrate the bowel close to cystic or tumoral intra abdominal structures. Our personal experience and recent data of the literature are reported.

Ultrasonography of the spermatic cord in children with testicular torsion: impact on the surgical strategy.

PURPOSE: Many surgeons advocate systematic exploration for acute scrotum rather than risking a misdiagnosis of testicular torsion. Study of testicular vascularization with color Doppler sonography (CDS) can be inaccurate, leading to dangerous false-negative results. We determine whether direct visualization of the twisted cord during emergency high resolution ultrasonography (HRUS) is a reliable sign to diagnose the torsion and whether its absence can dispense with unnecessary surgery. MATERIALS AND METHODS: From 1993 to 2002 an average of 35 patients per year presented with acute scrotum, and 44 patients had spermatic cord torsion. CDS and HRUS were performed in all cases. Transversal and longitudinal scans on both sides of the scrotum permitted comparison of testicular echogenicity, size and vascularization. The spermatic cord was studied along its complete length to detect spiral twist. The surgical findings were correlated with the preoperative results. RESULTS: Spermatic cord torsion at surgery was confirmed in all 44 cases. The time lost by the examination was never more than 30 minutes. Intratesticular blood flow was absent in the affected testis in 31 cases, and CDS was unreliable in the others. In all cases, regardless of CDS findings, HRUS succeeded in detecting the twist as a snail shell-shaped mass measuring 11 to 33 mm. CONCLUSIONS: The finding of a twisted spermatic cord is a highly reliable sign for the diagnosis of testicular torsion. Whereas normal intratesticular perfusion does not dispense with emergency exploratory surgery, direct and complete visualization of a nontwisted spermatic cord strongly indicates that surgery is unnecessary. Strict conditions are required, including time spent on HRUS should not exceed 30 minutes, which generally can only be achieved by a senior pediatric radiologist.

Sonographic diagnosis of colitis in children.

To assist the radiologist in differentiating the colitis in children, this review proposes a systematic US approach to the disease, presents the US aspect of the normal colon and describes three distinctive US patterns reflecting the intramural extension of the histopathological changes. Each pattern corresponds to one or several diseases producing alterations in the same layer(s). Stratified thickening suggests an inflammatory mucosal process resulting from infection (as in advanced appendicitis or in infectious colitis) or to inflammation (as in IBD). Nonstratified thickening with loss of the haustral folds reflects a marked submucosal infiltrate. Color Doppler is required to distinguish between an inflammatory disease (as advanced CD or neutropenic colitis) and an ischemic colitis (HUS in children). Nonstratified thickening with preservation of the length of the haustral folds is the sign of an intraluminal deposit due to PMC. Correlating the sonographic pattern and the anatomic distribution of the disease with the clinical and laboratory findings often permits to propose a specific diagnosis.

MRI of fetal GI tract abnormalities.

We describe the magnetic resonance (MR) patterns of a variety of fetal gastrointestinal (GI) abnormalities. Thirty-two fetuses between 23 and 38 weeks' gestation with abnormal appearance of the GI tract by ultrasound underwent MR imaging with T1- and T2-weighted sequences. The MR aspect of intestinal atresia (duodenal atresia, one case; small bowel atresia, nine cases) included dilatation of the bowel loops, accurate assessment of the normal bowel distal to the atresia (except in the patient with multiple atresia and apple-peel syndrome), and micro-rectum with decreased T1 signal (except in the patient with duodenal atresia). Megacystis-microcolon-intestinal hypoperistalsis syndrome (one case) was indicated by an abnormal signal of the entire bowel and an abnormal pattern for the urinary tract. Meconium pseudocysts (two cases) were easily differentiated from enteric cysts (two cases). High anorectal malformations with (two cases) or without (one case) urinary fistula and cloacal malformation (one case) are described and MR findings are discussed. The capability of MR imaging to demonstrate the normal bowel with intraperitoneal anomalies (e.g., congenital diaphragmatic hernia, and sacrococcygeal teratoma) is emphasized. MR imaging is informative in the diagnosis of GI tract abnormalities, especially the severe malformations, with much more accuracy than sonography.

[Rare vesical malformations]. / Malformations vésicales rares.

Ultrasonography has radically changed the approach of these rare malformations, still diagnosed with difficulties in spite of modern iconography. Bladder anomalies may easily be discovered when associated with otherwise obvious malformations of genitalia. The rest must be suspected for non-specific signs as micturition troubles, multiple urinary tract infections, chronic renal failure. The abnormal bladder is the only common feature of a polymorphic spectrum of diseases including complete or partial duplication or septum, congenital diverticula, vesicovaginal fistula, agenesis and urachal anomalies. Treatment must be accorded to each case and it needs perfect knowledge of open and endoscopic bladder surgery.

[Localized hypertrophic neuropathy (LHN) of the brachial plexus: diagnosis and presurgical evaluation with MRI]. / Neuropathie hypertrophique localisée (NHL) du plexus brachial: diagnostic et bilan préoperatoire par l'IRM.

The authors report a case of localized hypertrophic neuropathy diagnosed by MRI. This 10-year-old girl presented with painless progressive deltoid atrophy. Electrodiagnostic studies demonstrated chronic denervation. An MRI performed with T1, T2, T1 with gadolinium and fat saturation sequences showed a linear 5-cm long segment of hypertrophic brachial plexus cord, with moderate high T2, intermediate T1 signal, and marked post-Gadolinium enhancement. Progressive improvement followed surgical resection with nerve graft repair. Histological study confirmed LHN (perineurial cell proliferation), a rare cause of peripheral neurological deficit. MRI findings may suggest LHN, that should be suspected as well as peripheral nerve compression or tumor; inflammatory neuritis and idiopathic lesion (with normal MRI findings) remain a diagnosis of exclusion. MR aids in the precise localization of the lesion before surgery.

Advanced cranial ultrasound: transfontanellar Doppler imaging in neonates.

We know that many cerebral lesions are of circulatory origin and it is now important to study cerebral hemodynamics by pulsed and color Doppler ultrasonography. The revolution in the imaging of vascular physiology, the diagnosis, and the prognostic evaluation of vascular disease are not based on morphological sonographic studies but on the Doppler techniques that can display cerebral vessels in the neonate. The results of the hemodynamic investigation in 491 newborns aged from 32 weeks of gestation to 9 months by means of pulsed and color Doppler are reported. Normal values of the resistive index, peak systolic, end-diastolic, and time-averaged velocities in seven different vessels are determined. Some pathological examples are presented. Doppler techniques play a major role in the diagnosis, follow-up, and management of brain damage, whether ischemo-hemorrhagic, infectious, or developmental or tumoral, and of pericerebral collections.

[Brain sonography in 2001. Evaluation of macrocrania in the infant]. / L'échographie cérébrale en l'an 2001. Le point sur l'exploration d'une macrocrânie du nourrisson.

Transfontanelle sonography has become a routine imaging modality to assess infants with macrocrania: detection of hydrocephalus and diagnosis of its underlying etiology, detection and mapping of extra-axial collections, value of Doppler US for diagnosis of intracranial lesions, hemodynamic evaluation using pulsed Doppler imaging.

[Lower pole pedicle in a series of 84 pyelo-ureteral junction syndromes surgically treated in children]. / Le pédicule polaire inférieur dans une série de 84 syndromes de la jonction pyélo-urétérale opérés chez l'enfant.

OBJECTIVE: To evaluate the involvement and consequences of the lower pole pedicle (LPP) associated with ureteropelvic junction syndrome. MATERIAL AND METHOD: Retrospective study in 81 children presenting a total of 84 ureteropelvic junction syndromes operated consecutively between 1994 and 1998. Urinary tract ultrasound and cystography were systematically performed. Renal scintigraphy (DTPA or MAG 3) was performed in 80 children. Preoperative intravenous urography was performed in 60 children. LPP was considered to be present when its participation in the obstruction was confirmed intraoperatively (Anderson Hynes technique with uncrossing of the vascular pedicle). RESULTS: Group I: a LPP was revealed in 24 kidneys (28.5% of cases), 17 left kidneys and 7 right kidneys, in 14 boys and 10 girls, with a mean age of 4 years (range: 2 months-14 years). Group II: 60 kidneys without LPP (71.5% of cases), 32 left kidneys and 28 right kidneys, in 40 boys and 17 girls, with a mean age of 2 years (range: 1 month-15 years). The most frequent presenting complaint was recurrent low back pain in 58% of cases in group I (14/24) and 5% of cases in group II (3/60). The mean age at diagnosis was 6 years. Hydronephrosis was detected by antenatal ultrasound in 33% of cases in group I (8/24) and in 72% of cases in group II (43/60). Kidney function in group I was greater than 40% in 19 patients, between 20 and 39% in 2 patients and less than 20% in 2 patients. These results were not influenced by age at diagnosis and were not significantly different from those observed in group II. Renal malrotation was observed in 2 cases in group I and in 12 cases in group II. Histology of the junction revealed nonspecific fibrosis in the same percentage of cases (91%) in the two groups. The mean follow-up was 15 months (range: 2 months-5 years). No surgical failure was observed. CONCLUSION: Ureteropelvic junction syndrome associated with a LPP appears to present later with recurrent low back pain in older children. It does not worsen the functional prognosis of the affected kidney. LPP can be visualized by duplex ultrasound. It may act as an inducer of obstruction by aggravating a pre-existing abnormality of the ureteropelvic junction. When LPP is associated with isolated dilatation of the pyelocaliceal cavities, the risk of subsequent decompensation requires closer ultrasound surveillance, until puberty.

Comparison of ultrasound and dimercaptosuccinic acid scintigraphy changes in acute pyelonephritis.

The strategy for morphological investigations in children with acute pyelonephritis (APN) remains debatable. We studied 70 children (median age 2.0 years) admitted with a first episode of pyelonephritis using a high-resolution ultrasound technique (RUS) and compared the results with 99m technetium-dimercaptosuccinic acid (DMSA) renal scintigraphy. The DMSA scan was abnormal in 62 children (89%). However, using a high-frequency transducer we found abnormal sonogram changes in 61 children (87%), consisting of an increased kidney volume in 42, and/or a thickening of the wall of the renal pelvis in 42, and/or a focal hyper- or hypoechogenicity in 36, and/or a diffuse hyperechogenicity in 31 children. Micturating cystourethrography was performed in all children, revealing vesicoureteral reflux (VUR) in 22 (31%). Among those children with VUR, 4 had a normal DMSA scan, 2 an abnormal RUS, and 2 a normal DMSA scan and RUS. Our data suggest that B-mode RUS performed with a high-frequency transducer by a trained radiologist is nearly as sensitive as the DMSA scan in diagnosing renal involvement in children with unobstructed APN and in predicting VUR.

Spiral twist of the spermatic cord: a reliable sign of testicular torsion.

BACKGROUND: Colour Doppler sonography (CDS) has become the procedure of choice in evaluating testicular perfusion but false negative findings have been reported. OBJECTIVE: To determine if direct visualisation of the twisted spermatic cord using high resolution US is a reliable sign to assess testicular torsion. MATERIAL AND METHODS: Thirty patients (aged 2-26 years) with equivocal diagnosis of testicular torsion prospectively underwent high resolution and CDS. The results were correlated with surgical findings. Serial transverse and longitudinal scans were performed to compare the scrotal contents on each side and study the complete spermatic cord course, from inguinal canal to testis, to detect a spiral twist. RESULTS: In 14 of the 23 cases of torsion, the diagnosis was based on the colour Doppler findings in the scrotum because blood flow was absent in the symptomatic testis and detectable without difficulty on the normal side. In nine cases, CDS was unreliable; in six cases intratesticular perfusion was present in a twisted testis and in three small boys, no colour signal was obtained in either testis. In all cases of torsion, the spiral twist of spermatic cord was detected at the external inguinal ring. The twist induced an abrupt change in spermatic cord course, size and shape below the point of torsion. It appeared in the scrotum as a round or oval, homogeneous or heterogeneous extratesticular mass with or without blood flow, that could be connected cephalad with the normal inguinal cord. In the other seven cases (three late torsions of the appendix testis, one epididymo-orchitis and three torsions with spontaneous reduction), no spiral twist was detectable. CONCLUSION: The detection of spermatic cord spiral twist appears a reliable US sign of torsion whatever the testicular consequences.

Atypical pyloric stenosis in an infant with familial hyperlipidemia.

A 1-month-old infant presented with a typical pattern of pyloric stenosis but US revealed an intense hyperechogenicity of the thickened pyloric muscle. Cholecystitis and pancreatitis were also present in this child. Familial hyperchylomicronemia was detected. Surgery confirmed the fatty infiltration of the pyloric muscular layer, which was necrotic and inflammatory. Medical management with restriction of fat in the diet led to a complete recovery. This is an exceptional case of pyloric stenosis where the particular echographic appearance of the pyloric muscle led to successful to medical treatment.

Evaluation of abdominal pain in Henoch-Schönlein syndrome by high frequency ultrasound.

The authors report the use of high frequency ultrasound (7.5-10 MHz probes) for the detection of intestinal complications in 14 children with Henoch-Schönlein purpura. Ultrasound gave information of 3 levels: (1) It explained the acute abdominal pain by showing in all cases the oedematous haemorrhagic infiltration of the intestinal wall, which appeared thickened (3-11 mm): lesions were diffuse (6 cases) or focal (duodenal in 5 cases, jejunal in 2 cases and ileal in one). (2) It followed the evolution of the disease: extension of lesions (5 cases) or resolution (progressive decrease of parietal thickening, reexpansion of small bowel lumen, reappearance of peristalsis). (3) It always detected surgical complication: ileo-ileal intussusception (3 cases), perforation (1 case).

Pericerebral fluid collections and ultrasound.

The authors have studied 142 cases of pericerebral fluid collection, by ultrasound. Three echographic patterns are individualized: anechogenic single compartment (109); thin linear echogenic membrane dividing the pericerebral fluid collection (25); the third group (8) presented with a peripheric echogenic collection. The use of high frequency probes permits the detection of pericerebral effusions, and provides new information about the high incidence. Ultrasound can define the anatomical position and show the complications which are mainly acute subdural hematoma.