Pediatric hypertension: an approach to imaging | SpringerLink

Pediatric Radiology

Pediatr Radiol (1986) 16:461-467

© Springer-Verlag 1986

Pediatric hypertension: an approach to imaging M. J. Diament 1, P. Stanley 1, M. I. Boechat 2, H. Kangarloo 2, V. Gilsanz 1 and E. R. Lieberman 3 1 Department of Radiology, Childrens Hospital of Los Angeles 2 Department of Radiologic Sciences, UCLA Center for the Health Sciences, and 3 Department of Pediatrics, Division of Nephrotogy, Childrens Hospital of Los Angeles, Los Angeles, California, USA

Abstract. Since 1981, we have made diagnoses of secondary hypertension using state of art imaging equipment in 18 pediatric patients. The most valuable tests were ultrasound in identifying renal parenchymal disease, computed body tomography for adrenal tumors and intra-arterial renal angiography for renovascular disorders. Based on our experience, we have formulated an algorithm for the evaluation of the hypertensive pediatric patient. The initial step is careful clinical and laboratory screening to identify those patients that are likely to have essential hypertension and who should not undergo imaging tests. In the cases where there is a possible secondary etiology, renal ultrasound is usually performed first to identify parenchymal disease. If catecholamines are elevated, then abdominal computed tomography is the initial test. If no etiology is identified from these noninvasive studies, then direct intraarterial renal angiography is performed. The authors do not feel that excretory urography, radionuclide renography, intravenous digital subtraction angiography or selective renal vein sampling for renin are useful or practical screening tests for renovascular hypertension.

In recent years the problem of hypertension in pediatrics has received increased recognition [1, 2]. Previously, it was assumed that hypertension in children was secondary to definable etiologies, usually renal or renovascular disease [3]. Now that blood pressure is regularly measured as part of the routine care of children, a larger number are being recognized as having elevated blood pressure. The attending physician must decide whether or not these numbers signify a problem such that invasive tests are needed to

identify those conditions or which require surgery or angioplasty (PTA). With this problem in mind, we have reviewed our experience in the diagnosis of pediatric hypertension in selected patients since 1981, when state of art imaging equipment in all modalities was available at our institutions. Based on this analysis, we have formulated an approach to the sequential imaging evaluation of pediatric hypertension. Material and methods We retrospectively reviewed the medical records and imaging tests of hypertensive pediatric patients at Childrens Hospital of Los Angeles and UCLA Center for the Health Sciences who had an etiology established, primarily on the basis of imaging tests, since 1981. In order to make our results more relevant to the patient population seen in primary pediatric practice, we excluded patients who had hypertension complicating longstanding renal failure, neonates with umbilical artery catheters and renal transplants, Coarctation of the thoracic aorta was not included since the diagnosis was usually made by clinical examination and angiocardiography. We identified 18 patients ranging in age from 2 months to 16years. We divided the diagnoses into three categories: (A) renal parenchymal disease (Table 1), (B) endocrine neoplasms (Table 2); and (C) renovascular hypertension (Table 3). All computed tomograms of the body (CT) and all except one renal arteriogram (RA) (patient 2) were performed in our institutions. 131Iodine-Metaiodobenzylguanadine (MIBG) scans were done at Los Angeles County/University of Southern California Medical Center [4]. 1-t31 MIBG scintigraphy was performed following the intravenous injection of 0.5 mCi 1.7 m2 body surface area, using a gamma camera with a high-energy, parallel-hole collimator. Images were acquired for 100,000 counts or 20 min and were obtained at 24, 48, and occasionally 72 h after tracer injection, Posterior head and chest, posterior midadomen, and anterior lower abdominal images provided overlapping scans from the pelvis to the base of the skull on at least one imaging occasion. Thyroidal uptake of 1-131 was blocked by Lugol's solution, six drops per day (40 mg iodide) or three drops of saturated solution of potassium iodide (120 mg of iodide) per day beginning on the day before the tracer injection and continuing for at least four days afterwards.

Table I. Profiles of hypertensive patients. Renal parenchymal disease No. Age (years)

Sex

Blood a pressure

Symptoms

Physical exam.

Abnormal lab. tests

US

IVP

Other

Follow-up

1

F

160/110

None

Left flank mass

None

Left renal tumor

Same as US

CT-same as US

Normotensive after resection of Wilms' tumor

1½

2

16

M

240/170

Headache, seizures

Retinopathy

Proteinuria, pynria Cr ~ - 2.2

Bilateral upper pole scars

Not done

RA-bilateral upper pole scars. SVSnonlateralizing

Medical management, multiple antihypertensive medications

3

12

M

180/110

Headache, flushing, seizures

Refinopathy

Proteinuria Cr - 1.7

Left multicystic kidney. Hypoplastic ft. kidney

Nonfunctioning left kidney, Small right kidney

CT-neg. for pheochromocytoma. SVSNo lt. renal vein

Medical management, multiple antihypertensive medications

2/12

F

140/100

Diarrhea

Left flank mass

Proteinuria hematuria Cr - 1.5

Bilateral renal vein thrombosis

Not done

2

F

210/140

Seizures, coma

Retinopathy

Not available

Small left kidney

Nonfunctioning left kidney

4

Cr - serum creatinine in mg/dl;

a

Resolution of mass and hypertension with supportive care RN - poor function left kidney

Normotensive after left nephrectonay

approximate median blood pressure in mmHg off antihypertensive medication

Table 2. Profiles of hypertensive patients. Endocrine neoplasms No. Age Sex Blood pressure

Symptoms

Physical exam.

Lab. tests

CT

US

MIBG

SVS

Follow-up

6

9

F

210/140

Headache sweating coma

Retinopathy Elevated urinary and plasma catecholamines

3 cm rt. adrenal mass

Same

Not done

Not done

Normotensive after resection of adrenal pheochromocytoma

7

13

F

240/160

Headache blurred vision

Retinopathy

Elevated urinary and plasma catecholamines

3 cm lt. adrenal mass

Same

Left adrenal and paraaortic uptake

Elevated left adrenal catecholamines

Normotensive after resection of left adrenal and paraaortic pheochromocytomas

8

11

M

140/90

Sweating brother of no. 7

Normal


3 cm lt. adrenal ? paraaortic masses

3 cm It, adrenal mass

Left adrenal and multiple other sites of uptake

Elevated both adrenals and lt. iliac vein

Normotensive after resection of left adrenal pheochromocytoma

9

7

M

200/120

Headache vomiting cousin of no. 7

Retinopathy

Elevated urinary catecholamines


Not done

Not done

Not done

Normotensive after resection of right adrenal pheochromocytoma

10

6

M

150/110

Sweating and tachycardia

Normal


2½ cm left adrenal mass

Same as CT

Uptake lt. adrenal

Elevated left adrenal, ? right adrenal

Normotensive after resection of left adrenal pheochromocytoma

11

6

F

160/110

None

Short, cushingoid

Elevated serum cortisol


Same as CT

Not done

Not done

Normotensive after resection of right adrenal carcinoma

M. J. Diament et al.: Pediatric hypertension

463

Table 3. Profiles of hypertensive patients. Renovascular disease No. Age Sex Blood pressure

Symptoms

Physical exam.

Lab. tests IVP

US

12

1A M

210/120

Failure to thrive

Poorly Normal developed, CHF 2

13

1½ F

240/110

Failure to thrive

Poorly developed, retinopathy

14

5

F

140/100

Abdominal Epigastric mass, pain, headache bruit

LVH by EKG

Calcified mid abdominal mass, small lt. kidney

15

12

M

180/120

None

Obesity

Normal

Normal

RN - normal Segmental stenosis rt. upper pole

Normotensive after PTA

16

16

F

160/110

None

Severe JRA Normal

Normal

Rt. renal artery aneurysm, arteritis

Controlled by antihypertensive medications

17

12

M

210/140

Headache, seizures coma

Normal

Normal

Not available

Not available

Not available

Rt. renal artery stenosis


18

7

F

180/120

None

None

LVH by EKG

Small ft. kidney

Same as IVP

CT - same as IVP

Rt. renal artery stenosis

Normotensive after PTA. Successful surgery for recurrent stenosis

Not done

Proteinu- Small lt. ria kidney LVH 3 by EKG

Other

Normal

RA

Follow-up

Bilateral renal artery stenosis

Expired due to CHF

Not done CardiomegalyLeft renal artery stenosis


Same as IVP

Normotensive after surgical bypass. Successful PTA for recurrent stenosis

C T - same as IVP

Abdominal aneurysm, lt. renal artery stenosis

C H F - congestive heart failure; LVH - left ventricular hypertrophy

CTs were performed on third or fourth generation units with scan times of five seconds or less. Intravenous digital subtraction arteriography (DSA) was performed on commercially available units using central lines placed in the right atrium. RA was recorded either on cut film or, in the past two years, with digital subtraction techniques [51. Aortography and selective injections of each kidneys in both obliquities were obtained unless the aortogram demonstrated severe main renal artery stenosis. Radionuclide renograms (RN) were performed with both Technetium 99 m Pertechetate (DTPA) and Hippuran isotopes. Ultrasound (US) examinations were performed on commercially available gray scale scanners using real-time and, in some cases, static B scans. All US and CT studies were complete examinations of the abdomen and pelvis.

Results

For renalparenchymal disease, US was positive in all five patients. The excretory urogram (IVP) also demonstrated abnormalities in the three patients in whom it was done. R N scans also had positive results in the two cases where they were applied. Once CT scan was performed in patient 1 with Wilms' tumor and the other done in patient 3 who had multicystic dysplasia on the left and contralateral hypo-

plasia because pheochromocytoma was still suspected despite negative ultrasound scans of the adrenals and normal catecholamine studies. Selective venous sampling (SVS) for renin and DSA were performed in this patient. The SVS was unsatisfactory because no renal vein could be identified for the multicystic kidney. The DSA demonstrated absent arterial supply to the multicystic kidney. Of the endocrine neoplasms, there were five patients with pheochromocytoma and one with an adrenal carcinoma. The five children with pheochromocytoma all had adrenal tumors ranging from 2.5 to 4 cm in diameter. The adrenal carcinoma was about 6 cm in diameter. CT was employed in all of the patients and correctly identified all adrenal neoplasms. CT did not identify the multiple paraaortic pheochromocytomas, which were less than 1 cm in diameter (patient 7), and was suggestive of multiple sites in patient 8, in whom several less than 1 cm inflammatory paraaortic nodes were seen. US was used in four patients with pheochromocytomas and in the one with adrenal carcinoma. It was positive for all adrenal lesions and did not suggest an extra

464

M.J. Diament et al.: Pediatric hypertension

Fig. I a-c. An intravenous digital subtraction angiogram demonstrates an aneurysm at the bifurcation of the main renal artery (arrow). No abnormality was appreciated on the left side. b A selective direct arterial subtraction angiogram on the right confirms the presence of the aneurysm, c A selective direct arterial injection on the left demonstrates irregularity of the peripheral renal arteries. Patchy perfusion of the parenchyma was noted on the capillary phase

IBOE E 160-

Q.

t40-

n

0

0

O

•

0

.~ 120- • "6

"~ 100iJ

°

•

O

f

Q

1'0

~'s

Age (years)

Fig.2. Distribution of systolic blood pressures by diagnosis. O Renal parenchymal disease; [] endocrine tumor; • renovascular disease

adrenal site in the one patient with multicentric disease. MIBG scans were employed in three patients. It was the only test to identify the patient with multicentric disease. However, it was also falsely positive for multicentric disease in another case. SVS was likewise employed in three patients and was false negative for the multicentric patient and false positive for multicentricity in the other two. One IVP was performed in a child with pheochromocytoma and was normal. All patients with pheochromocytoma had positive studies for at least one of the urinary catecholamines, and in the four cases in which plasma catecholamines were evaluated the levels were also elevated. Four patients with pheochromocytomas were from a single kindred. CT was performed on several other family members who were normotensive and had negative catecholamines. CT was negative in all

of these cases and no further studies were performed [41. For renovascular disease, we considered RA to be the diagnostic standard. No test other than RA was performed consistently in these patients. The IVP was the next most commonly done study and was abnormal, demonstrating unilateral hypoplasia, in three of the five patients in whom it was performed. US was abnormal in two of three. Only one intravenous DSA (patient 16) was performed. It correctly identified a right renal aneurysm, but did not show arteritis in the contralateral kidney which was identified by RA (Fig. 1 a-c). Only one RN was performed and it was negative. A C T was done in patient 14 who presented with a mid-abdominal mass that was later shown by arteriography to be an abdominal aortic aneurysm with bilateral renal artery stenosis. No SVS for renin was done. Five of the patients underwent PTA [61. In one patient, surgery was later performed because of recurrent stenosis. The rest are normotensive with followup ranging up to 4 years. Another child who underwent surgical bypass later had a successful PTA of an anastomotic stenosis. The patient with a renal artery aneurysm and arteritis is being treated medically. The 6-month-old infant with bilateral renal artery stenosis later expired because of severe congenital cardiac disease. Discussion

Our patients represent a very selected group among those with hypertension who have been referred to tertiary care centers. Thirteen of the 18 were symptomatic and blood pressure was moderately to severely elevated (Fig. 2).


.~/../Clinical Possible secondary hypertension

and laboratory evaluation

465

~...~.~ Probable essential hypertension

Possiblepheochromocyt oma Observation, diet, medication yes// "~.~No ~.Poorresponse .,~--~/ ~ ' -Good - - ~response Catech~olamines "~-- US Elevated Normal~J'Parenchyn~al disease Normal Tumor IVP,RN,VCUG RA kCTJ Pond N'~egative Negative Positive Surgery, PTA Essentialhypertension SVS,MIBG

Surgery

A profile of the patient who is likely to have a positive diagnostic imaging evaluation emerges from our study. He or she is likely to be preadolescent, symptomatic, have moderately to severely elevated blood pressure and may have evidence of endorgan response such as retinopathy or left ventricular hypertrophy. Neurofibromatosis [7, 8] or a family history of endocrine neoplasm may be present. On the other hand, the adolescent with labile mild hypertension and without abnormalities on urinalysis, urine culture and serum creatinine is more likely to have essential hypertension [9]. The referring clinician must take all of these factors into account before deciding whether to initiate an imaging evaluation. If imaging studies are indicated, the first test that we recommend for most patients is US. If abnormalities such as cystic disease, hydronephrosis or renal scarring are detected, then follow-up examinations such as IVP, RN and/or VCUG may be indicated. If US demonstrates unilateral or bilateral hypoplasia of the kidneys then the clinical examination and the results of the urinalysis and urine culture should suggest whether this is due to renovascular or parenchymal disease and indicate the appropriate followup studies. If an abdominal mass is detected, then the next study will usually be CT. If the patient already has studies showing elevated urinary or plasma catecholamines, then we recommend CT as the initial exam (Fig.3). We and others [10] have not had difficulty in the identification of adrenal pheochromocytoma by abdominal CT in a patient with elevated catecholamines using currently available equipment. If the study were to be negative, the CT examination should be to include the chest and the neck [10]. If

Fig. 3. Suggested algorithm for the sequential evaluation of hypertensive patients. Some patients with smooth, renal hypoplasia may undergo renal arteriography rather than IVP for evaluation for parenchymal disease depending on the clinical findings

this were also negative, then MIBG or SVS could be used as supplementary studies. Neither SVS or MIBG were sufficiently sensitive or specific in our limited experience to recommend them as routine studies. Since pheochromocytoma is a rare lesion in pediatrics, it seems likely that further experience will be required before recommendations for clinical use of these studies can be given. At the present time, surgical exploration with subsequent relief of hypertension must be considered the definitive diagnostic standard [4]. If US is negative then our recommendation is that RA be performed. We have not found IVP or RN to be sufficiently sensitive to serve as screening tests [11-15]. We feel intravenous DSA is inappropriate in most pediatric cases since it still requires sedation in uncooperative patients and cannot identify peripheral renal arterial disease [16, 17] which is relatively more common in children than adults. Therefore, both positive and negative DSA would require follow-up with conventional RA. However, we now employ digital subtraction techniques routinely for our direct arterial angiograms. SVS for renin has a limited role in pediatric renovascular disease. It can usually be assumed that renal arterial stenosis demonstrated by angiography in a hypertensive child is functionally significant [18]. On the other hand, an elevated unilateral or segmental renin is of doubtful clinical value if technically adequate selective renal arteriograms are negative. The saralasin infusion test has been proposed as a screening test for pediatric hypertension, but it requires that the patient be salt depleted and off all antihypertensive medication [19]. Its clinical validity has not been established in pediatrics. SVS may be of value when small, rare re-


466

nin or aldosterone secreting tumors are suspected [20]. Much of the impetus for screening for renovascular hypertension has been to attempt to avoid the potential morbidity of RA. However, with the advent of digital subtraction techniques, we have been able to do all of our studies with four or five French catheters. All of our examinations are done with basal sedation, without a general anesthetic. Blood pressure is controlled by medication prior to performing the examination and an indwelling line is present to administer emergency drugs if needed. Patients are usually admitted directly to the radiology department on the morning of the examination and are discharged home later in the day. At Ch:ildrens Hospital of Los Angeles, there have been no complications from RA in the past 10 years, except for groin hematomas. Using this combination of clinical and imaging screening, over 70% of our RA have been positive for lesions that are treatable either by surgery or PTA. Our approach differs in several important respects from previously advanced protocols for the evaluation of the hypertensive child. The most important one relates to the recognition of the prevalence of high blood pressure in children, probably reflecting an increased detection of essential hypertension in this age group. It is for this reason that we place considerable reliance on clinical screening for our patients [9, 21], since uncritical application of imaging tests in a population with a low prevalence of secondary causes will inevitably lead to a relatively large number of false positive diagnoses [22] and performance of increasingly invasive diagnostic studies. If the patient appears to be high risk for having secondary hypertension or fails to respond to medical management, then imaging tests are warranted. We have discontinued the use of IVP as an initial study preferring to perform US instead. US has the advantage of being noninvasive, not subjecting the patient to radiation and being more diagnostic in patients with decreased renal function or extrarenal neoplasms. The one disadvantage of US relative to IVP seems to be its decreased sensitivity in the detection of renal scarring [23]. However, the only patient with this disorder in our study was detected by US. It is as our impression that the ability to detect focal scars has increased with improvements in US technology including computerized phased array and focused annular array transducers. Nevertheless, if scarring is still suspected despite a negative ultrasound, then either an IVP - possibly with nephrotomography - or Technetium 99 m Succimer (DMSA) may be helpful in excluding this diagnosis

prior to performing arteriography. None of the tests employed in this study were sensitive enough to be characterized as screening tests for renovascular disease. Recently, Technetium DMSA [24, 25], has been advocated as a screening test for pediatric renovascular hypertension. However, in the largest study [24] only nine of thirteen patients with renovascular lesions had abnormal DMSA scans. The other study [25] do not include a large enough number of patients with renovascular lesions to evaluate either a sensitivity or specificity. Clearly our protocol is not meant to be exclusive or rigid. The evaluation of the patient depends on the clinicians prior experience, the desires of the patient and family and the expertise available in the various diagnostic imaging and therapeutic modalities. However, in view of the rapid development of new imaging methods and the refinement in therapeutic techniques, especially the development of PTA and surgical procedures designed to repair renovascular lesions while preserving renal parenchyma [15], reevaluation of the approach to an increasingly recognized problem is warranted.

References 1. Kotchen TA, Kotchen JM (1983) Significances of high blood pressure in the young. In: Kotchen TA, Kotchen JM (eds) Clinical approaches to high blood pressure in the young. John Wright, Littleton, MA, p 1 2. Report of the task force on blood pressure control in children (1977) Pediatrics 59:797 3. Olson DL, Lieberman E (1976) Renal hypertension in children. Pediatr Clin North Am 23: 795 4. Turner M, DeQuattro V, Falk F, Ansari A, Lieberman E (1986) Childhood familial pheochromocytoma: conflicting results of localization techniques. Hypertension (in press) 5. Stanley P, Diament MJ (1984) Intra-arterial DSA in children. Radiology 153:172 (Abstract) 6. Stanley P, Hieshima G, Mehringer M (1984) Percutaneous transluminal angioplasty for pediatric renovascular hypertension. Pediatr Radiol 153:101 7. Mena E, Bookstein J J, Holt JF, et al (1973) Neurofibromatosis and renovascular hypertension in children. Am J Roentgenol 118:39 8. Glushien AS, Mansy MM, Littman DS (1953) Pheochromocytoma: its relationship to neurocutaneous syndromes. Am J Med 14:318 9. Lieberman E (1986) Hypertension in childhood and adolescence. In: Kaplan H (ed) Clinical hypertension, 4th edn. Williams and Wilkins, Baltimore (in press) 10. Farrelly CA, Daneman A, Martin D J, et al (1984) Pheochromocytoma in childhood: the important role of computed tomography in tumor localization. Pediatr Radiol 14: 210 - 214 11. Stanley P, Gyepes MT, Olson DL, Gates GF (1978) Renovascular hypertension in children and adolescents. Radiology 129:123 12. Stanley JC, Fry WJ (1981) Pediatric renal occlusive disease and renovascular hypertension. Etiology, diagnosis, and operative treatment. Arch Surg 116:669

M. J. Diament et al.: Pediatric hypertension 13. Hillman BJ, Ovitt TW, Capp M P (1982) The potential impact of digital video subtraction angiography on screening for renovascular hypertension. Radiology 1142: 577 14. Hillman BJ, Ovitt TW, Capp MP (1982) The potential impact of digital video subtraction angiography on screening for renovascular hypertension. Radiology 1142: 577 15. Gomes AS, Pats SO, Barbaric ZL (1983) Digital subtraction angiography in the evaluation of hypertension. A JR 140:779 16. Watson AR, Balfe JW, Hardy BE (1985) Renovascular hypertension in childhood: a changing perspective in management. J Pediatr 106:366 17. Kirks DR, Fitz CR, Korobldn M (1977) Intrarenal collateral circulation in the pediatric patient. Pediatr Radiol 5:154 18. Doody PT, Wombolt DG, Tynes WV, et al. (1982) Intrarenal arterial stenosis. Clin Pediatr 21 : 32 t9. Ernest CB (1983) Childhood renovascular hypertension. In: Kotchen TA, Kotchen JM (eds) Clinical approaches to high blood pressure in the young. John Wright, Littleton, Mass, p151 20. Gillespie L, Elnrlich RM, Marks LS, et al (1980) Use of saralasin to detect renovascular hypertension in childhood. Urology 16:453 21. Ganguly A, Bergstein J, Grim CE, et al. (1980) Childhood primary aldosteronism due to an adrenal adenoma: preoperative localization by adrenal vein catheterization. Pediatrics 65: 605

467 22. Maxwell MH, Waks AU (1984) Evaluation of patients with renovascular hypertension. Hypertension 6:589 23. Gelfand DW, Ott DJ (1985) Methodologic considerations in comparing imaging methods. ~OR 144:117 24. Kangarloo H, Gold RH, Fine RN, Diament M J, Boechat MI (1985) Urinary tract infection in infants and children evaluated by ultrasound. Radiology 154:367 25. Stringer DA, deBruyn R, Dillon MJ, Gordon I (1984) Comparison of aortography, renal vein renin sampling, radionuclide scans, ultrasound and the IVU in the investigation of childhood renovascular hypertension. Br J Radiol 57:111 26. Rosen PR, Treves S, Ingelfinger J (1985) Hypertension in children. AJDC 139:173

Received: 3 October t985; accepted: 24 February 1986

Dr. M.J. Diament Department of Radiology Childrens Hospital Los Angeles California 90024 USA

Literature in pediatric radiology (continued from p. 460) MR appearance of blood and blood products: An in vitro study, Cohen, M.D. et al. (Dept. of Rad., James Whitcomb Riley Hosp. for Children, Indiana Univ. Sch. of Med., 702 Bamhill Dr., Indianapolis, IN46223, USA) 146, 1293 (1986) Archives of Surgery (Chicago)

Presentation of congenital diaphragmatic hernia past the neonatal period. Newman, B.M. et al. (Dept. of Surg., Box 181, Univ. of Virginia Mud. Center, Charlottesville, VA 22908, USA) 121, 813 (1986) Clinical Nuclear Medicine (Philadelphia)

Extraosseous uptake of technetium-99m MDP in secondary deposits of neuroblastoma. Mandell, G. A., Heyman, S. (Dept. of Mud. Imaging, A. t. duPont Inst., P.O. Box 269, Wilmington, Delaware 19899, USA) 11, 337 (1986) Scintigraphic findings in infantile hemangioendothelioma. Noel, A.W., Hayman, S. (Children's Hosp. of Philadelphia, Dept. of Rad., Philadelphia, PA 19104, USA) 11, 413 (1986) Scintigraphic manifestation of fibrous dysplasia. Machida, K. et al. (Saitama Med Center, Saitama Mud. Sch., Dept. of Rad., 1981, Kamocla, Kawagoe, Saitama, Japan) 11,426 (1986) Computerized Radiology (Emsford)

Symmetrical low density areas in bilateral thalami in an infant with measles encephalitis, Ochi, J. et al. (Dept. of Ped., Kyoto Univ. Sch. of Mud., 54 Kawaharacho, Shogoin, Sakyo-ku, Kyoto 606, Japan) 10, 137 (1986) Journal of Computer Assisted Tomography (Bethesda)

MR imaging of bone marrow in children. Kangartoo, H. et al. (Dept. of Pad. Sci, Univ. of California at Los Angeles, Sch. of Mud, Los Angeles, CA 90024, USA) 10, 205 (1986) MR imaging of hemophiliac arthropathy. Kulkarni, M.V. et at. (Dept. of Rad., Univ. of Texas Health Sci. Center, 6431 Fannin, 2.134 MSB, Houston, TX 77030, USA) 10, 445 (1986) CT appearance of nidus in osteoid osteoma versus sequestration in osteomyelitis. Malboubi, S. (Dept. of Rad., Children's Hosp. of Philadelphia, PA, USA) ~!0,457 (1986) MR imaging of intraspinal extension of neuroblastoma. Siegel, M.J. et al. (Mallinckrodt Inst. of Rad., Washington Univ. Sch. of Mud., 510 South Kingshighway Blvd., St. Louis, M r 63110, USA) 10, 593 (1986)

Journal of Nearosurgery (Baltimore)

Intracranial arachnoid cysts in children. Rutherford, G. et al. (M. Edwards, Dept. of Neurol. Surg., c/o The Editorial Office, 1360 Ninth Ave., Suite 210, San Francisco, CA94122, USA) 64, 835 (1986) Journal of Nuclear Medicine (New York)

Scanning with iodine-131 MIBG in children with solid tumors: An initial appraisal. Hadley, G. P., Rabe, E. (Dept. of Paed. Surgery, Univ. of Natal, P.O. Box 17039, 4013 Congella, Durban, Natal, South Africa) 27, 620 (1986) Gastroesophageal scintiseanning in a pediatric population: Dosimetry. Castronovo, F. P., Jr. (Dept. of Rad., Massachusetts Gun. Hosp., Boston, A02114, USA) 27, 12t2 (1986) Pediatric radiation dose from (11lin)leukocystes, arcus, C. ~Harbor-UCLA Mud. Center, Torrance, CA, USA) 27,1220 (1986) Journal of Pediatrics (St. Louis)

Clinical utility of magnetic resonance imaging in pediatric neurosurgical patients. Hanigan, W.C. et al. (Dept. of Neurosciences, 530 N.E. Glen Oak Ave., Peoria, IL 61637, USA) 108, 522 (1986) Intracardiac thrombi complicating central total parenteral nutrition: Resolution without surgery or thrombolysis. Mendoza, G.J. et al. (Brown, E.G., Dept. of Ped., The Mount Sinai Mud. Center, Fifth Ave. at 100th St., New York, NY 10029, USA) 108, 610 (1986) Journal of Pediatric Surgery (Orlando)

Blunt liver trauma in children: The role of computed tomography in diagnosis and treatment. Vock, P. et al. (Dept. of Diagn.-Rad., Univ. Hosp., CH-3010 Bum, Switzerland) 21,413 (1986) Hepatoblastoma and hepatocarcinoma in children: Analysis of a series of 29 cases. Gauthier, IF. et al. (Serv. de Chir.-Infantile, Hfp. de Bic~tre, 78, ave. du C~nrral Leclerc, F-94270 Le K.remlin-Bic~tre,France) 21, 424 (1986) Bilateral tracheal bronchi. Cope, R. et al. (Cambell, J.R., Dept. of Ped.-Surg., Oregon Health Sci. Univ., Portland, OR 97201, USA) 21, 443 (1986) Use of iohexol in the radiographic diagnosis of ischemic bowel. Schwartzentruber, D.J. et al. (J. L. Grnsfeld, Dept. of Surg., Indiana Univ. Med. Center, 702 Barnhill Dr, Indianapolis, IN 46223, USA)21, 525 (1986) Portal vein ultrasonography in the early diagnosis of necrotizing enterocolitis. Lindley, S. et al. (D.L.Mollitt, Univ. Hosp. of Jacksonville, 655 W Eighth St, Jacksonville, FL 32209, USA) 21, 530 (1986) (continued on p. 474)