Smaller Ventricular Size Research Articles

Ethmoidal meningoencephalocele and CSF leak after posthaemorrhagic ventricular dilatation in a newborn child

Rhinoliquorrhoea suggests a communication between the subarachnoid space and the sinonasal tract. Clinical presentation includes clear nasal discharge, headache, pneumocephalus, meningitis or brain abscess. Cerebrospinal fluid (CSF) leaks are mostly of traumatic origin (skull base fractures), iatrogenic (secondary to endoscopic endonasal surgery) or associated with tumour aetiology. Occasionally, hydrocephalus has been the cause of rhinoliquorrhoea in adults, presumably secondary to the chronically raised intracranial pressure with skull base erosion and meningocele. To our knowledge, the association of hydrocephalus and ethmoid meningoencephalocele/CSF leak has not been previously reported in a newborn child. We present the case of a 9-month-old girl who was referred for rhinorrhoea. She had a history of posthaemorrhagic ventricular dilatation. Brain computed tomography (CT) and magnetic resonance imaging (MRI) showed a left ethmoidal meningoencephalocele and small ventricular size. The meningoencephalocele was surgically repaired using an intradural subfrontal approach. During the postoperative period, after the transient lumbar drain was withdrawn, she developed symptomatic hydrocephalus. Ventriculoperitoneal shunting was required. Progressive ventricular dilatation may arise from a meningoencephalocele/CSF leak in paediatric patients. Early identification and repair of the meningoencephalocele are critical to avoid development of complications.

GENDER DIFFERENCES IN PATIENTS WITH PRESERVED EJECTION FRACTION, LOW-FLOW, LOW-GRADIENT SEVERE AORTIC STENOSIS

Preserved ejection fraction, low-flow, low-gradient (PLFLG), severe aortic stenosis (AS) is characterized by small left ventricular (LV) cavity size, excessive concentric remodeling, and subclinical LV dysfunction. The extent of these characteristics, however, varies in any given individual with

(219) - Role of VAD Therapy for Patients with Restrictive Cardiomyopathy: Improving Outcomes for a Lethal Disease

Restrictive cardiomyopathy (RCM), regardless of etiology, is generally associated with very poor outcome. Because of the small ventricular size, conventional continuous flow VAD therapy is generally not used for the treatment of end stage heart failure related to RCM. In our center, we have used VAD therapy in selected patients whose outcome would otherwise be very poor, or those we felt could be bridged to transplant (BTT). The goal of this study was to examine our experience and look for factors that may predict better outcome following LVAD implantation for end-stage RCM patients.

Patients with small left ventricular size undergoing balloon aortic valvuloplasty have worse intraprocedural outcomes

To evaluate the impact of left ventricular (LV) chamber size on procedural and hospital outcomes of patients undergoing aortic valvuloplasty. Balloon aortic valvuloplasty (BAV) is used as an integral step during transcatheter aortic valve implantation. Patients with small, thickened ventricles are thought to have more complications during and following BAV. Retrospective study of consecutive patients with severe, symptomatic calcific aortic stenosis who underwent retrograde BAV at Massachusetts General Hospital. We compared patients with left ventricular end-diastolic diameters (LVEDD) <4.0 cm (n = 31) to those with LVEDD ≥4.0 cm (n = 78). Baseline and procedural characteristics as well as clinical outcomes were compared. Multivariate logistic regression was used for the adjusted analysis. Patients with smaller LV chamber size were mostly women (80.7% vs. 19.4%, P < 0.01) and had a smaller body surface area (BSA), (1.61 ± 0.20 m(2) vs. 1.79 ± 0.25 m(2) , P < 0.01). Patients with smaller LV chamber size had higher ejection fractions and thicker ventricles. Otherwise, baseline characteristics were similar. The intraprocedural composite of death, cardiopulmonary arrest, intubation, hemodynamic collapse, and tamponade was higher for patients with LVEDD < 4.0 cm (32.3% v. 11.5%, P = 0.01). Adjusting for age, gender, BSA, LV pressure, and New York Heart Association class, LVEDD < 4.0 cm remained an independent predictor of procedural (OR 5.1, 95% CI 1.4-18.2) and in-hospital complications (OR 3.8, 95% CI 1.2-11.6). Compared to patients undergoing BAV with LVEDD ≥4.0 cm, those with smaller LV chambers had worse procedural and in-hospital outcomes.

Image-guided cerebrospinal fluid shunting in children: catheter accuracy and shunt survival

Object Cerebrospinal fluid shunt placement has a high failure rate, especially in patients with small ventricles. Frameless stereotactic electromagnetic image guidance can assist ventricular catheter placement. The authors studied the effects of image guidance on catheter accuracy and shunt survival in children. Methods Pediatric patients who underwent placement or revision of a frontal ventricular CSF shunt were retrospectively evaluated. Catheters were placed using either anatomical landmarks or image guidance. Preoperative ventricular size and postoperative catheter accuracy were quantified. Outcomes of standard and image-guided groups were compared. Results Eighty-nine patients underwent 102 shunt surgeries (58 initial, 44 revision). Image guidance was used in the placement of 56 shunts and the standard technique in 46. Shunt failure rates were not significantly different between the standard (22%) and image-guided (25%) techniques (p = 0.21, log-rank test). Ventricular size was significantly smaller in patients in the image-guided group (p &lt; 0.02, Student t-test) and in the surgery revision group (p &lt; 0.01). Small ventricular size did not affect shunt failure rate, even when controlling for shunt insertion technique. Despite smaller average ventricular size, the accuracy of catheter placement was significantly improved with image guidance (p &lt; 0.01). Shunt accuracy did not affect shunt survival. Conclusions The use of image guidance improved catheter tip accuracy compared with a standard technique, despite smaller ventricular size. Failure rates were not dependent on shunt insertion technique, but an observed selection bias toward using image guidance for more at-risk catheter placements showed failure rates similar to initial surgeries.

Slit Ventricle Syndrome

Slit ventricle syndrome is a rare condition whereby brain compliance is reduced and can be associated with intermittent intracranial hypertension. A 19-year-old male with a ventriculoperitoneal shunt for congenital hydrocephalus presented with a 1-day history of headache and drowsiness-symptoms from which he suffered in many recurrent episodes over the past 5 years. The improvement of headaches without surgical intervention led to the diagnosis of migraine. During this hospitalization, episodes of intermittent intracranial hypertension were documented along with the remission and relapse of the symptoms. While the patient's intracranial pressure was within normal range in over 90% of his monitoring period, which postponed shunting, replacement of his ventriculoperitoneal shut eventually resolved his symptoms. Slit ventricle syndrome with reduced ventricular compliances should be considered in patients with clinical evidence of intermittent intracranial hypertension and small ventricular size. The authors advocate shunt replacement as an appropriate treatment for this condition.

HASTE MRI in the assessment of children with hydrocephalus

Background Recent reports and our clinical experience have shown the usefulness of rapid-acquisition MRI in evaluating children with hydrocephalus. An axial HASTE (i.e. Half-Fourier Acquisition Single-shot Turbo Spin Echo Magnetic Resonance Imaging) MRI study acquires clinically useful images in seconds without exposing children to the risks of ionizing radiation or sedation. The current report reviews the Seattle Children’s Hospital experience with rapid acquisition MRI in shunted children with attention to ventricular size, overall image quality, motion artifact, and catheter visualization. Materials and methods All HASTE MRIs obtained at Seattle Children’s Hospital over two-years were reviewed by two evaluators on scales of overall image quality, catheter visualization, motion artifact, and ventricular size. Relationships among these factors were sought. Results Overall image quality was rated very good or excellent in 94% of the studies reviewed, while only one study was graded as poor. Significant motion artifact was noted in 7% while 77% had little or no motion artifact. Catheter visualization was rated as good or excellent in 57% of studies reviewed, poor in 36%, and misleading in 7%. Small ventricular size showed a significant correlation with poor catheter visualization (Pearson correlation coefficient = .575; p<.00001). Ventricular enlargement concerning for shunt malfunction on HASTE imaging correlated with operative findings of shunt malfunction in 100% of cases taken to the OR based on HASTE imaging. Conclusions Our study adds further support to the emerging evidence that HASTE MRI is an adequate substitute for CT scanning allowing for reduced utilization of CT imaging and resultant exposure to ionizing radiation. Visualization of catheter position remains suboptimal with HASTE MRI, particularly when ventricles are small; however, shunt malfunction can be adequately determined based on ventricular size alone in the majority of cases.

On-Off Malfunctıon In A Pedıatrıc Shunt: A Case Report

3 years-old-boy with a history of ventriculo-peritoneal shunt placement was admitted to our neurosurgery department with headache, vomiting and sunset eye phenomena. Direct X-ray examination of the shunt system was completely normal. The palpation of the shunt dome resulted the unfilling of pumping device. Computerised tomography (CT) of the head revealed ventricular enlargement and periventricular oedema. The patient was hospitalised for shunt revision. The symptoms were spontaneously disappeared within 48 hours. The pumping device returned to normal refilling. Follow up CT showed small ventricular size and shape. This case indicates that the symptomatic intermittent occlusion of the proximal shunt catheter can be seen in the paediatric age group and the obstruction may continue for a certain period and spontaneously return to normal function with correlated clinical response.

On-Off Malfunctıon In A Pedıatrıc Shunt: A Case Report

3 years-old-boy with a history of ventriculo-peritoneal shunt placement was admitted to our neurosurgery department with headache, vomiting and sunset eye phenomena. Direct X-ray examination of the shunt system was completely normal. The palpation of the shunt dome resulted the unfilling of pumping device. Computerised tomography (CT) of the head revealed ventricular enlargement and periventricular oedema. The patient was hospitalised for shunt revision. The symptoms were spontaneously disappeared within 48 hours. The pumping device returned to normal refilling. Follow up CT showed small ventricular size and shape. This case indicates that the symptomatic intermittent occlusion of the proximal shunt catheter can be seen in the paediatric age group and the obstruction may continue for a certain period and spontaneously return to normal function with correlated clinical response.

Index of Suspicion in the Nursery

A 2.6-kg infant was born at 38 weeks’ gestation to a 16-year-old G1P0 woman. The prenatal history included maternal Chlamydia infection. The baby was delivered via emergent cesarian section because of nonreassuring fetal heart tones. His Apgar scores were 7 and 9 at 1 and 5 minutes, respectively. He exhibited tachypnea and hypoxia at birth, with a respiratory rate of 80 to 100 breaths/min, grunting, chest retractions, and coarse breath sounds. Other than a mild systolic ejection murmur, the remainder of the physical examination findings were normal. The baby's A-a gradient (a measure of the difference in the partial pressure of oxygen in the alveolar spaces and the arterial blood) was elevated, initially 473 mm Hg on 100% Fio2. Chest radiographs showed no signs of acute air space disease for the first several postnatal weeks. Over the next several months, the infant continues to have a respiratory rate of 60 to 90 breaths/min, with increased work of breathing, gradually requiring increases in supplemental oxygen to achieve an Spo2 in the mid-90s. Chest computed tomography (CT) scan performed at 2 weeks of age showed attenuation of the pulmonary vasculature and hyperinflation of the lungs. Although motion artifact limited the evaluation, the chest CT showed no focal lung opacities and no other anatomic defects. Repeated echocardiography revealed a small patent foramen ovale (left-to-right shunt) and normal ventricular size and function. Multiple therapies are tried without obvious …

A Reliable and Efficient Method for Cerebral Ventricular Volumetry in Pediatric Neuroimaging

Cerebral ventricular volume has the potential to become an important parameter in quantitative neurological diagnosis. However, no accepted methodology for routine clinical use exists to date. We sought a robust, reproducible, and fast technique to evaluate cerebral ventricular volume in young children. We describe a novel volumetric methodology to segment and visualize intracerebral fluid spaces and to quantify ventricular volumes. The method is based on broadly available T1 weighted volumetric magnetic resonance (MR) imaging, an interactive watershed transform, and a fully automated histogram analysis. We evaluated this volumetric methodology with 34 clinical volumetric MR datasets from non-sedated children (age 6-7 y) with a history of prematurity and low birth weight (< or = 1500 g) obtained during a prospective study. The methodology, with adaptation for small ventricular size, was capable of evaluating all 34 of the pediatric datasets for cerebral ventricular volume. The method was a) robust for normal and pathological anatomy, b) reproducible, c) fast with less than five minutes for image analysis, and d) equally applicable to children and adults. Clinical brain ventricular volume calculations in non-sedated children can be performed using routine MR imaging besides efficient three-dimensional segmentation and histogram analysis with results that are robust and reproducible.

Can prenatal ultrasound findings predict ambulatory status in fetuses with open spina bifida?

Objective: To determine whether prenatal sonographic findings in fetuses with open spina bifida can predict ambulatory potential and the need for postnatal shunt placement. Study Design: Ongoing pregnancies complicated by isolated open spina bifida from January 1996 to March 2000 were studied retrospectively. Static images and reports generated every 3-4 weeks from diagnosis until delivery were reviewed for lesion level and type, ventricular width, and lower extremity appearance. Operative summaries as well as neonatal and pediatric charts were reviewed. Ambulatory was defined in infants ≥2 years old as walking with or without appliances. In those <2 years of age, ambulatory was defined as at least 4/5 lower extremity muscle strength. Results: Thirty-three cases of isolated open spina bifida were identified. Lower (more caudal) lesion levels and smaller ventricular size were associated with ambulatory status in univariate analyses (P <.001, P =.003, respectively). No infant with a thoracic lesion was ambulatory (n = 11); all had ventriculomegaly diagnosed prenatally and all required shunt placement. In contrast, all infants with L4-sacral lesions (n = 10) were ambulatory, and 60% had ventriculomegaly diagnosed prenatally. Of patients with L1-L3 lesions (n = 12), 50% were ambulatory. In this group, ambulatory potential could not be determined by the presence of ventriculomegaly, ventricular size, or the presence of club foot. In the entire cohort, no infant with a myeloschisis was ambulatory, and all infants except one with a sacral lesion required postnatal shunt placement. Conclusions: Sonographic determination of lesion level and type is useful in predicting the ambulatory potential of fetuses with open spina bifida. (Am J Obstet Gynecol 2001;185:·1016–20.)

Association of brain structural change with the heterogeneous course of schizophrenia from early childhood through five years subsequent to a first hospitalization

Fifty first-episode patients with schizophrenia were followed for 5 years subsequent to their first hospitalization. The course of illness was charted prospectively and premorbid childhood histories were obtained retrospectively at the initial evaluation, and MRI scans were obtained initially and at each follow-up. Fifteen different life-time patterns of illness course emerged, although none were specifically associated with structural brain change. A deterioration in premorbid scores was positively correlated with larger ventricular volume at the first hospitalization, and the larger the ventricles, the less the subsequent change in ventricular size thereafter. An analysis to see whether initial hemispheric and ventricular size could predict different course types only revealed that patients with an acute onset and complete recovery had significantly smaller ventricles than all others. No differences emerged for initial hemispheric size. Thirty-four percent of patients individually showed some association of brain ventricular size and 28% hemisphere volume reductions with fluctuation in psychotic symptoms. Paradoxically, most showed larger ventricles and smaller hemispheres to be associated with clinical improvement, rather than the predicted reverse. These latter data question the notion that the structural brain changes seen over time in some patients are related to poor outcome, although small ventricular size in those patients with acute onset may be predictive of recovery. Thus, brain structural change is occurring early in the course of illness and may be a consequence of the process leading to resolution.

Automated Left Ventricular Endocardial Border Detection Using Acoustic Quantification in Children.

OBJECTIVES: The purpose of this study was to determine the reliability and accuracy of automated border detection using acoustic quantification in children. BACKGROUND: Acoustic quantification has shown promise in adult patients as a method for on-line estimation of left ventricular size and function. However, in children, the smaller ventricular size might magnify the importance of measurement error. METHODS: We compared the cross-sectional area and fractional area change of the left ventricle as measured on line by acoustic quantification with the area and fractional area change derived by hand-digitizing the endocardial border of the left ventricle off line, both with and without the papillary muscles included in the left ventricular cavity. RESULTS: The areas and area change fractions from the two methods were highly correlated, both with inclusion and exclusion of the papillary muscles for off-line analysis. However, the regression slope was closer to unity when the papillary muscles were excluded from the left ventricular cavity during off-line digitization of the endocardial border. Analysis of agreement between the two methods showed good agreement for area measurements and fair agreement for function measurements. The magnitude of the difference between the two methods for area measurement was directly proportional to the size of the ventricle. That is, the larger the ventricle the larger the difference between the area measurements by the two methods. DISCUSSION: Automatic border detection using acoustic quantification appears to be an acceptable method for estimating the cross-sectional area and fractional area change of the left ventricle in children.

The mitral valve prolapse--panic disorder connection.

Whether mitral valve prolapse (MVP) is more common in patients with panic disorder (PD) and agoraphobia with panic attacks (AgP) than in the normal population is controversial. A related issue is whether the presence of MVP in such patients has any clinical or biological significance. Echocardiograms were performed on 36 patients with PD/AgP and 22 normal controls. MVP was found to be more common in PD/AgP patients than in normal controls. However, MVP in the patients was mild and not associated with thickened mitral leaflets or small left ventricular size. Moderate or severe prolapse was uncommon in both groups. Patients with MVP had trends to higher heart rate and prolonged QTc interval on EKG, and reported more respiratory difficulty during panic attacks compared to patients without MVP. Lactate infusion did not affect patients with MVP differently than patients without MVP. The authors conclude that MVP is more common in patients with PD or AgP than in normal controls, but is of doubtful clinical significance.

Two-Dimensional and Doppler Echocardiographic Assessment of Infiltrative Cardiomyopathy

Infiltrative cardiomyopathies can be divided by disease into infiltrative and storage disorders that show an increase in ventricular wall thickness caused by infiltration of pathologic substances between cells, as with amyloid and sarcoid, or deposition within cells, as with iron, glycogen, and lipid. Two-dimensional and Doppler echocardiography are powerful noninvasive tools in the assessment of the anatomic and functional characteristics of these disorders. With cardiac amyloidosis as the prototype, the constellation of findings of a small or normal left ventricular cavity size; markedly increased thickness of the ventricular walls, associated with a highly abnormal texture; and biatrial enlargement make up its characteristic appearance. However, there is a wide spectrum of abnormalities in this disorder, depending on the stage and duration of heart involvement. Doppler assessment of diastolic function is frequently abnormal in cardiac amyloidosis. Cardiac sarcoidosis usually is evident by a dilated segmental cardiomyopathy with regional wall abnormalities. Similarly, hemochromatosis appears as a dilated cardiomyopathy with normal wall thickness. The echocardiographic appearance of glycogen and glycolipid storage diseases is similar to cardiac amyloidosis, and biochemical analysis may be necessary for differentiation. Thus echocardiography is an important tool in the characterization of infiltrative cardiomyopathies.

Relationships between intracranial pressure, ventricular size, and resistance to CSF outflow.

In 230 patients with normal-pressure hydrocephalus, high-pressure hydrocephalus, or benign intracranial hypertension, measurements of the intracranial pressure (ICP), ventricular size, and cerebrospinal fluid (CSF) outflow resistance (Ro) have revealed a linear relationship between ICP and Ro. It is shown that on average the CSF formation rate tends to decrease with increasing ICP. It is also shown that the size of the ventricles increases as the ICP levels off toward normal values. The clinical implication of this is that a small or normal ventricular size in acute or subacute phases does not preclude defective CSF resorption.

Computed tomography in affective disorders. Part II. Brain density

The attenuation values of brain density were investigated in 53 patients with affective disorder and 53 individually age- and sex-matched controls by computed tomography (CT). Asymmetry of density distribution, with higher values in most regions of the left hemisphere, was found in patients as well as in controls. Patients tended to display higher attenuation values than controls. In patients, an association between higher density of the parenchyma and smaller ventricular size was observed, but not in controls. Corresponding greater density in patients, compared to controls, was found in those subgroups (women, nonpsychotics, and bipolars) that did not differ in ventricle size from controls. Comparisons within subgroups of patients revealed lower attentuation values in psychotic than in nonpsychotic subjects, lower values in men than in women, lower values in lithium-treated than in non-lithium-treated patients, and lower values in unipolar than in bipolar patients. No differences were observed between older and younger patients or Dexamethasone Suppression Test (DST) normal versus DST-abnormal patients. No correlations between age and density were obtained in patients and controls.

Surgical treatment of double inlet ventricle ("single ventricle").

The surgical techniques described are the result of an evolution over a number of years in the performance of the septation operation and the modified Fontan-Kreutzer repair for patients with double inlet ventricles. Those with associated pulmonary stenosis are best palliated by a classical Blalock-Taussig or Goretex shunt if an operation is required during the first few years of life and later, between two and four years of age, definitive repair by the modified Fontan-Kreutzer operation is advised. Although controversial, we prefer the use of a large nonvalved right atrial-pulmonary artery connection. Ventricular septation remains the best definitive surgical option when pulmonary stenosis is absent or mild. It is contraindicated by severe pulmonary vascular disease and also by less than moderate ventricular enlargement. The need for concomitant AV valve replacement and the use of an extracardiac conduit are associated with increased hospital mortality in our experience. Infants identified during the first year of life who do not have pulmonary stenosis are a difficult subset to manage. If the VSD and subaortic area is large and unobstructed, pulmonary artery banding early in life will control pulmonary vascular resistance and from this standpoint, permit these patients to become ultimately suited to a modified Fontan-Kreutzer repair. Unfortunately, ventricular hypertrophy usually results from pulmonary artery banding and has been associated with higher hospital mortality at the time of definitive repair. When pulmonary artery banding is undertaken for this subset, debanding and definitive repair seems best advised at about two years of age. Pulmonary artery banding is well known to accelerate the development of subaortic stenosis by spontaneous progressive restriction of the VSD. This results in small ventricular cavity size and increased ventricular hypertrophy, which are incremental risk factors for increased hospital mortality by either definitive procedure. When the VSD or subaortic area is narrow and the patient is identified during the first year of life, isolated pulmonary artery banding is inappropriate. The surgical options for these patients include Ebert's two-stage management program consisting of the initial placement of a loose partial septation patch with concomitant pulmonary artery banding, and later debanding and complete septation. Alternatively, a trial of primary complete septation may be warranted, or the use of a procedure consisting of division of the main pulmonary artery with distal closure and anastomosis of the proximal portion to the side of the ascending aorta, coupled with a systemic-pulmonary artery shunt.

Septation of the univentricular heart with left anterior subaortic outlet chamber

Surgical repair by ventricular septation was accomplished in 16 patients with univentricular heart of the left ventricular type, two atrioventricular (AV) valves, and a left anterior subaortic outlet chamber. There were seven hospital deaths (44%; CL 29% to 60%), six from low cardiac output, including each of five patients with outlet foramen obstruction (100%; LC 68% to 100%), In the subset of 11 patients with unobstructed outlet foramen, there were only two deaths (18%; CL 6% to 38%), both in patients with small ventricular size. Multivariate analysis in the group of 16 patients indicates that small ventricular size and again the presence of outlet foramen obstruction are incremental risk factors for hospital death. No late deaths occurred among nine survivors followed between 2 months and 4 years (median = 1.5 years). Only one patient was taking cardiac medication and each was in New York Heart Association Functional Class I. Late postoperative exercise testing in seven showed good exercise tolerance, although values were below normal for children of similar age. Planned initial palliation, appropriate timing to repair, appropriate patient selection, and improving surgical methods should reduce hospital mortality further. The late functional results are encouraging and support continuation of this surgical procedure in patients with suitable anatomy.