Silent cerebral emboli following percutaneous closure of atrial septal defect in pediatric patients: a diffusion-weighted MRI study

PURPOSE

The aim of this prospective study was to investigate the incidence of silent cerebrovascular embolic events associated with percutaneous closure of atrial septal defect (ASD) in pediatric patients.

METHODS

A total of 23 consecutive pediatric patients (mean age, 10.4±3.8 years; range, 4–17 years) admitted for transcatheter closure of ASD were recruited in the study. The patients were scanned with a 1.5 Tesla clinical scanner. Two cranial magnetic resonance imaging (MRI) examinations were acquired before the procedure and within 24 hours following the catheterization. MRI included turbo spin-echo fluid-attenuated inversion recovery (FLAIR) sequence and diffusion-weighted imaging technique with single-shot echo-planar spin-echo sequence. The transcatheter closure of ASD was performed by three expert interventional cardiologists. Amplatzer septal occluder device was implemented for the closure of the defect. No contrast medium was administered in the course of the procedure.

RESULTS

None of the patients had diffusion restricted cerebral lesions resembling microembolic infarctions on postprocedural MRI. Preprocedural MRI of two patients revealed nonspecific hyperintense white matter lesions on FLAIR images with increased diffusion, which were considered to be older ischemic lesions associated with previously occurred paradoxical embolism.

CONCLUSION

The current study suggests that percutaneous closure of the ASD, when performed by experienced hands, may be free of cerebral microembolization in pediatric patients. However, due to the relatively small sample size, further studies with larger patient groups are needed for the validation of our preliminary results.Acute symptomatic cerebral infarction associated with percutaneous cardiovascular intervention has been reported to have an incidence of 0.09%–1.0% when evaluated solely with neurologic examination (1–4). However, asymptomatic cerebral microemboli detected with transcranial Doppler ultrasonography (US) monitoring and diffusion-weighted imaging (DWI) following either conventional or interventional cardiac catheterization is unexpectedly more common (4–10). The incidence revealed with DWI studies varies between 3.3% and 77% depending on risk factors associated with the patient population and the procedure, in adult studies (9, 10).Due to technologic developments, more children with congenital heart disease are taken to the cardiac catheterization laboratory for interventional treatment. The subclinical focal neurologic events are more difficult to reveal solely with neurologic examination in children compared with the adult age group. Therefore, it is crucial to determine the silent neurologic complications and the risk factors associated with heart catheterization in the pediatric population. There have been a few studies in adults (10–12), but to the best of our knowledge, no clinical studies revealed the association of subclinical ischemic lesions with transcatheter closure of atrial septal defect (ASD) in pediatric patients.Transcatheter closure of ASD, which is an alternative to open heart surgery, is applied as a first-line treatment modality in appropriate patients (13). Despite increasing rates of complete closure with ongoing technologic innovations, neurologic complications associated with peri-interventional cerebral embolism have been reported (10, 11). In this single-center, prospective study, we aimed to investigate the incidence and the risk factors of silent cerebral embolism following transcatheter closure of ASD with the Amplatzer septal occluder (AGA Medical Corp.) device in pediatric patients.     

Audiological findings in otospondylomegaepiphyseal dysplasia (OSMED) associated with a novel mutation in COL11A2

The aim of the study was to assess the audiological findings of a 4-year-old child with a homozygous COL11A2 mutation and to point out the role of continuous follow-ups in children with craniofacial syndromes after the newborn hearing screening. A 4-year-old boy with otospondylomegaepiphyseal dysplasia (OSMED) was followed up after birth for hearing loss. Transient Otoacoustic Emissions (TEOAEs), Distortion Product Otoacoustic Emissions (DPOAEs), Automated and Clinical Auditory Brainstem Response (AABR and ABR) measurements, Visual Reinforcement Audiometry, immitansmetric measurements and hearing threshold measurements were performed for audiological evaluation. The patient developed sensorineural hearing loss at 11 months of age while his hearing was normal at birth. Because of auditory-verbal training with hearing aids started at 20 months of age, he now has normal verbal communication with his peers. This study clearly demonstrates that hearing loss develops in infancy in patients with OSMED and underscores the importance of continued hearing screening beyond newborn period for early intervention of hearing impairment and communication problems.     

Cutaneous silica granuloma: a lesion that might be clinically underdiagnosed

Cutaneous silica granuloma is a poorly understood, uncommon condition. There have been relatively few reports of cutaneous silica granuloma despite the well-known ubiquitous nature of silica in the environment. The characteristic latency period between the time of silica exposure to the time of clinical onset of granuloma, lack of clear-cut histories of exposure in most cases and likelihood of spontaneous resolution, may challenge the diagnosis. Thus, cutaneous silica granuloma might be a lesion that is often underdiagnosed. Here we describe a patient with characteristic findings of cutaneous silica granuloma.     

Quantitative Assessment of the Hepatic Metabolic Volume Product in Patients with Diffuse Hepatic Steatosis and Normal Controls Through Use of FDG-PET and MR Imaging: A Novel Concept

Aims and Objectives  

The aim of this study was to compare hepatic standardized uptake values (SUVs) and hepatic metabolic volumetric products (HMVP) between patients of diffuse hepatic steatosis and control subjects with normal livers.     

Pseudo-Kaposi sarcoma: a challenging vascular phenomenon

Pseudo-Kaposi sarcoma is a rare vascular phenomenon which can be related to congenital vascular malformations or acquired venous insufficiency. The differential diagnosis includes Kaposi sarcoma. In this report, a patient with Pseudo-Kaposi sarcoma Stewart-Bluefarb subtype is presented and the related literature is reviewed.     

When do we need contrast-enhanced CT in patients with vague urinary system findings on unenhanced CT?

Determination of renal neoplasms, hematoma, infarct, urinoma, cysts, and pyelonephritis may require contrast material administration following unenhanced CT in patients with flank pain. In this pictorial review, we aimed to clarify when contrast material administration is needed following vague urinary system findings on unenhanced CT. Erhan Akpinar and Baris Turkbey contributed equally to this work.     

Surgical treatment outcome of subdural empyema: A clinical study

A retrospective study of 28 patients identified with subdural empyema (SE) at the Department of Neurosurgery between the years 1995 and 2005 was carried out. SE occurred in all patients following bacterial meningitis. The six most frequently encountered clinical features included: (1) fever in 22 (79%) patients; (2) disturbed consciousness in 16 (57%) patients; (3) papilledema in 11 (39%) patients; (4) hemiparesis in 4 (14%) patients; (5) meningismus or meningeal signs in 4 (14%) patients, and (6) seizures in 3 (11%) patients. In the majority of cases, the most frequent causative pathogen of SE was Staphylococcus aureus. Surgery was performed on all patients, which included craniotomy in a group of 20 patients and burr hole drainage in a group of 8 patients. In conclusion, we believe that infants and young children should be carefully monitored following meningitis, in case of SE development, and that surgical intervention in patients presenting with meningitis may facilitate the development of SE. Furthermore, from a surgical point of view, our experience has led us to believe that craniotomy in comparison with burr hole surgery is the best surgical modality for management of SE as the recurrence rate of SE associated with burr hole surgery is high.     

Decreased paraoxonase1 activity and increased malondialdehyde and oxidative DNA damage levels in primary open angle glaucoma

To investigate the malondialdehyde (MDA) levels, paraoxonase1 (PON1) activity and 8-hydroxy 2-deoxyguanosine (8-OHdG) levels in the primary open angle glaucoma (POAG) patient. Blood samples from 52 healthy individuals and 53 patients with POAG were analyzed for MDA and 8-OHdG by HPLC (high-performance liquid chromatography) and PON1 by spectrophotometry. The data obtained were analyzed statistically. MDA levels were 10.46±8.4 and 4.70±1.79 μmol; PON1 levels were 121±39.55 and 161.62±60.22 U/mL; and 8-OHdG values were 1.32±0.53/106 dG and 0.47±0.27/106 dG in the POAG patients and the control group, respectively. The difference was significant in MDA levels, 8-OHdG levels and PON1 activity in POAG patients in comparison with controls (P<0.001). We concluded that the observed increase in MDA and 8-OHdG levels may be correlated with decreased PON1 activity. Oxidative stress plays an important role in glaucoma development.