2011-Q2 Literature Summary

CHILDREN’S HOSPITAL BOSTON LIBRARY

CURRENT AWARENESS SERVICE

Topic: Pediatric Interventional Radiology

1. Alejandre-Lafont E, Krompiec C, Rau WS, Krombach GA. Effectiveness of therapeutic lymphography on lymphatic leakage. Acta Radiol. 2011;52(3):305-11. PMID: 21498367

BACKGROUND: The number of conventional lymphographies has declined markedly since the introduction of cross-sectional imaging techniques. Nevertheless, lymphography has a high potential as a reliable method to visualize and directly occlude lymphatic leaks. When used as a distinct radiological procedure with the intention to treat, this application can be described as therapeutic lymphography.

PURPOSE: To investigate if therapeutic lymphography is a reliable method to treat lymphatic leakage when conservative treatment fails and to investigate which parameters influence the success rate.

MATERIAL AND METHODS: Between August 1995 and January 2008, 50 patients with lymphatic leakage in form of chylothorax, chylous ascites, lymphocele, and lymphatic fistulas underwent conventional therapeutic lymphography after failure of conservative therapy. Of these 50 patients, seven could not be statistically evaluated in our retrospective study: one patient died of cancer 1 day after lymphography, and six were excluded due to various technical problems. The remaining 43 patients were evaluated. Therapeutic success was evaluated and correlated to the volume of lymphatic leakage (more or less than 500 mL/day), as assessed by drainage.

RESULTS: In nearly 79% of patients, the location of the leak could be detected, and surgical intervention could be planned when therapeutic lymphography failed. Due to the irrigating effect of the contrast medium (lipiodol), the lymphatic leak could be completely occluded in 70% of patients when the lymphatic drainage volume was less than 500 mL/day. Even when lymphatic drainage was higher than 500 mL/day, therapeutic lymphography was still successful in 35% of the patients. The overall success rate in patients with failed conservative treatment was 51%. Success did not depend on other factors such as age and sex, cause of lymph duct damage, or time elapsed between lymphatic injury and intervention.

CONCLUSION: Therapeutic lymphography is an effective method in the treatment of lymphatic leakage when conservative therapy fails. The volume of lymphatic drainage per day is a significant predictor of the therapeutical success rate.

2. Arnold RW, Janitz E, Poulton TB, Bacic J, Frush DP. Pulmonary CT angiography to evaluate for pulmonary embolism in children visiting adult-centered community hospitals. AJR Am J Roentgenol. 2011;196(6):W823-30. PMID: 21606276

OBJECTIVE: The objective of our study was to determine the rate of pulmonary embolism (PE) on pulmonary CT angiography (CTA) in children and adolescents visiting adult-centered community hospitals. We also investigated alternative diagnoses that may account for presenting symptoms.

MATERIALS AND METHODS: We identified consecutive children and adolescents (age </= 19 years) who underwent pulmonary CTA during a 12- and 24-month period, respectively, at two community hospitals. Staff radiologists’ clinical interpretations of pulmonary CTA studies were compared with interpretations performed by a blinded, subspecialty-trained thoracic radiologist, with a third tie-breaking interpretation performed in cases of discrepancy. A systematic review of pulmonary CTA studies for possible alternative diagnoses was completed. Diagnostic rates of PE on pulmonary CTA studies in adults at these hospitals were also reviewed for comparison.

RESULTS: The study population consisted of 130 individuals (32 boys and 98 girls; median age, 18 years; age range, 11-19 years) who underwent 137 examinations, 11 as inpatients and 126 as outpatients. CTA studies were positive for PE in six patients (4.6%). CTA showed an important alternative diagnosis, such as pulmonary consolidation, in 27 patients (21%). By comparison, pulmonary CTA studies in adults at these two hospitals yielded a 16% positive rate for PE.

CONCLUSION: The prevalence of PE in young ambulatory patients with clinically suspected PE at adult-centered community hospitals is substantially lower than in adults. Alternative diagnoses, such as pulmonary consolidation and pneumothorax, are discovered more frequently than PE on pulmonary CTA studies. Pulmonary CTA should be used with discretion in adolescents, especially when radiography may provide the necessary diagnosis.

3. Zakaria RH, Barsoum NR, El-Basmy AA, El-Kaffas SH. Imaging of pericardial lymphangioma. Ann Pediatr Cardiol. 2011;4(1):65-7. PMID: 21677810

Pericardial cystic lymphangioma is a developmental malformation of the lymphatic system. We report a case of cystic pericardial lymphangioma in the anterior mediastinum in a 1-year-old male child. The lesion was diagnosed with multidetector computed tomography and magnetic resonance imaging (MRI). Histopathological examination showed features of cystic lymphangioma.

4. Benedik MP, Zaletel M, Meglic NP, Podnar T. A right-to-left shunt in children with arterial ischaemic stroke. Arch Dis Child. 2011;96(5):461-7. PMID: 21377993

OBJECTIVE: To compare the prevalence and grade of right-to-left shunt (RLS) in children with arterial ischaemic stroke (AIS) and in controls. DESIGN: Prospective study. SETTING: Tertiary paediatric referral centre. Patients 30 consecutive children with AIS. INTERVENTION: Contrast transcranial Doppler (cTCD) with Valsalva manoeuvre was performed in children with AIS and in controls. MAIN OUTCOME MEASURES: Detection and quantification of RLS.

RESULTS: Logistic regression analysis showed that RLS was significantly associated with AIS and prothrombotic disorders or with AIS of undetermined aetiology (OR 6.10; 95% CI 1.41 to 26.3; p=0.015). The prevalence of RLS was significantly higher in a group of children with AIS and prothrombotic disorders or with AIS of undetermined aetiology compared to controls (p<0.05). Significantly more microembolic signals (MES) were detected in a group of children with AIS and prothrombotic disorders or with AIS of undetermined aetiology than in controls (p<0.005).

CONCLUSIONS: Both the prevalence of RLS and number of detected MES were significantly higher in a group of children with AIS and prothrombotic disorders or with AIS of undetermined aetiology compared to controls. These findings suggest that paradoxical embolism may be an underestimated cause of AIS in children, particularly those with AIS and prothrombotic disorders or with AIS of undetermined aetiology.

5. Moreno Alarcon C, Lopez Cubillana P, Capel Aleman A, Cao Avellaneda E. Hematuria secondary to congenital arteriovenous fistula treated with embolization. Arch Esp Urol. 2011;64(6):550-553. PMID: 21791722

OBJECTIVE: To report a rare case of hematuria caused by an arteriovenous fistula which may be a urological emergency. METHODS: We describe the medical history, physical examination, complementary tests performed and their results, as well as the treatment applied in an adolescent with hematuria.

RESULTS: Congenital arteriovenous fistula was diagnosed and treated by percutaneous embolization with immediate stop of hematuria.

CONCLUSION: Non-traumatic renal arteriovenous fistulae are rare, even more if they present with gross hematuria. We present a case of a life-threatening emergency caused by one of them the treatment of which was possible by embolization, avoiding surgery.

6. Sierpina DI, Chaudhary HM, Walner DL, Aljadeff G, Dubrow IW. An infantile bronchial hemangioma unresponsive to propranolol therapy: case report and literature review. Arch Otolaryngol Head Neck Surg. 2011;137(5):517-21. PMID: 21576565

7. Baspinar O, Mete A, Davutoglu V. Transcatheter closure of a large left ventricular pseudoaneurysm using an Amplatzer Vascular Plug 4 and stenting of the inferior caval vein in a child. Cardiol Young. 2011:1-4. PMID: 21740605

Left ventricular pseudoaneurysm is especially rare in childhood, and its main treatment option should be surgery. We describe the case of a 9.5-year-old boy who first underwent mitral vegetation excision and then an unsuccessful pseudoaneurysm operation. Owing to pseudoaneurysmal sac dimensions, inferior caval vein syndrome developed. We delivered the Amplatzer Vascular Plug 4 into the pseudoaneurysm and treated the inferior caval vein syndrome with a bare Cheatham-Platinum stent. The patient was asymptomatic at the last follow-up.

8. Bialkowski J, Akdeniz C, Celebi A. Transcatheter closure in two rare cases of left-to-right shunt with Cardio-O-Fix occluders. Cardiol Young. 2011:1-4. PMID: 21729493

We present two procedures of transcatheter closure: that of an aorto-pulmonary window in a 12-month-old infant with a body weight of 7 kilograms, and that of ruptured sinus of Valsalva aneurysm into the right atrium in an adult patient. In the first case, we applied the muscular ventricular septal defect Cardio-O-Fix, while in the other we applied the patent ductus arteriosus Cardio-O-Fix occluder. The procedures were successful in both patients, and we achieved complete closure of the unwanted shunts.

9. Widmann G, Schullian P, Haidu M, Bale R. Stereotactic Radiofrequency Ablation (SRFA) of Liver Lesions: Technique Effectiveness, Safety, and Interoperator Performance. Cardiovasc Intervent Radiol. 2011. PMID: 21671150

PURPOSE: To evaluate technique effectiveness, safety, and interoperator performance of stereotactic radiofrequency ablation (SRFA) of liver lesions.

METHODS: Retrospective review including 90 consecutive patients from January 2008 to January 2010 with 106 computed tomography-guided SRFA sessions using both single and multiple electrodes for the treatment of 177 lesions: 72 hepatocellular carcinoma (HCC) and 105 metastases with a mean size of 2.9 cm (range 0.5-11 cm). Technique effectiveness and 1-year local recurrence were evaluated by computed tomographic scans. Complications, mortality, and hospital days were recorded. The performance between an experienced and inexperienced interventional radiologist was compared.

RESULTS: The overall technique effectiveness after a single SRFA was 95.5% (93.1% for HCC and 97.1% for metastases). Four of the eight unsuccessfully treated lesions could be retreated (secondary technique effectiveness of 97.7%). Local recurrence at 1 year was 2.9%. Technique effectiveness was significantly different for lesions <5 cm (96.7%) and >5 cm (87.5%) (P = 0.044) but not for lesions <3 cm (95.9%) and 3-5 cm (100%). Compared to clear parenchymal property (97.3%), vessel vicinity (93.3%) (P = 0.349) and subcapsular (95.2%) (P = 0.532) had no, but hollow viscera vicinity (83.3%) had a significantly lower technique effectiveness (P = 0.020). Mortality rate was 0.9%. Major complications and hospital days were higher for cirrhosis Child-Pugh B (20%, 7.2 days) than Child-Pugh A (3.1%, 4.7 days) patients and for metastases (5.1%, 4.3 days). There was no significant difference in interoperator performance.

CONCLUSION: SRFA allowed for efficient, reliable, and safe ablation of large-volume liver disease.

10. Saliba Z, El-Rassi I, Smayra T. Percutaneous closure of a large iatrogenic fistula between the inferior vena cava and the pulmonary vein in a child. Catheter Cardiovasc Interv. 2011. PMID: 21780277

We hereby describe a complex late postoperative veno-venous fistula in a child, successfully treated by an interventional percutaneous procedure. It is a unique complication of diaphragmatic hernia surgery that has never been reported before: a late postoperative iatrogenic fistula, between the inferior vena cava and the right lower pulmonary vein, discovered in a 6-year-old boy operated at the age of 4 months for a right diaphragmatic hernia. The right to left shunt was completely and uneventfully suppressed by a percutaneous procedure separating the systemic venous return from the pulmonary venous return with an Amplatzer Vascular Plug II. (c) 2011 Wiley-Liss, Inc.

11. Rameau A, Anand SM, Nguyen LH. Ballpoint pen ingestion in a 2-year-old child. Ear Nose Throat J. 2011;90(7):E20-2. PMID: 21792786

A 2-year-old girl ingested a ballpoint pen, which was found on chest x-ray to have lodged in the lower esophagus and stomach. The pen, which measured nearly 15 cm in length, was removed via rigid esophagoscopy without complication. To the best of our knowledge, this is the longest nonflexible foreign body ingested by a young child ever reported in the English-language literature. We describe the presentation of this case and the current guidelines for safety as enumerated in the Small Parts Regulations established by the U.S. Consumer Product Safety Commission.

12. Puri AS, Rahbar R, Dearden J, Graham RJ, Lillehei C, Orbach DB. Stretched and sheared microcatheter retained after onyx embolization of infantile myofibromatosis. Interv Neuroradiol. 2011;17(2):261-6. PMID: 21696669

We describe a rare neurointerventional complication, namely a stretched and sheared microcatheter, extending 52 cm from its point of retention within an Onyx cast in an infant patient’s neck mass, to the groin. The tumor was an unusual manifestation of infantile myofibromatosis and prior attempts at resection had proven impossible due to bleeding. Recommendations regarding microcatheter selection, diagnostic workup, and management of the ensuing complication are given.

13. Sanger C, Wong L, Wood J, David LR, Argenta LC. Giant facial lymphangioma. J Craniofac Surg. 2011;22(4):1271-4. PMID: 21772195

Lymphatic malformation (LM) is a benign cystic entity resulting from aberrant lymphatic drainage. Often evident at birth, most LMs have declared themselves by 2 years of age. They can be concerning when they occur near vital structures such as the airway or orbit. The natural history varies considerable from spontaneous gradual regression to long-term growth and debilitation. Depending on the location, structures involved, and clinical course of the LM, therapeutic options include observation, intralesional sclerosis, laser therapy, and surgical excision. The literature provides guidelines for treatment options that must be carefully applied to the facial region. We present a newborn infant who presented to our institution with giant facial lymphangioma who underwent a combination of sclerosis, laser ablation, and surgery with reconstruction.

14. Imteyaz H, Karnsakul W, Levine MA, Burrows PE, Benson J, Hsu S, et al. An Unusual Case of Hypothyroidism in an Infant with Hepatic Hemangioma. J Pediatr Gastroenterol Nutr. 2011. PMID: 21716131

15. Lin HK, Lin CC, Tsai IC, Wang JD, Lin WY. Successful Treatment of Eosinophilia-associated Budd-Chiari Syndrome in a Child. J Pediatr Gastroenterol Nutr. 2011;53(1):106-8. PMID: 21694545

16. Potter C, Hogan MJ, Henry-Kendjorsky K, Balint J, Barnard JA. Safety of pediatric percutaneous liver biopsy performed by interventional radiologists. J Pediatr Gastroenterol Nutr. 2011;53(2):202-6. PMID: 21788763

OBJECTIVE: National data suggest that pediatric percutaneous liver biopsy is increasingly being performed by interventional radiologists rather than pediatric gastroenterologists. The objective of the present report is to describe the safety and effectiveness of percutaneous liver biopsy performed by interventional radiologists in a large cohort of children and to compare the results with the existing literature on biopsies performed by pediatric gastroenterologists.

PATIENTS AND METHODS: The medical records of 249 children undergoing ultrasound-guided percutaneous liver biopsy by interventional radiologists were reviewed for adverse events and success of obtaining tissue. Two hundred ninety-four biopsies were reviewed.

RESULTS: There were no deaths. There were 2 instances of a 2-g or greater drop in hemoglobin following biopsy, neither of which was associated with clinical signs of hemorrhage. A small, asymptomatic pneumothorax quickly resolved without treatment. One patient developed Klebsiella sepsis 48 hours after biopsy. In all but 1 case, an adequate sample size was obtained. This low incidence of adverse events compares favorably with existing published reports of morbidity and mortality following percutaneous liver biopsy performed by pediatric gastroenterologists.

CONCLUSIONS: Ultrasound-guided percutaneous liver biopsy performed by experienced pediatric interventional radiologists in a children’s hospital setting is as safe and effective as biopsy performed by pediatric gastroenterologists.

17. Fayad F, Sellier N, Chabaud M, Kazandjian V, Larroquet M, Raquillet C, et al. Percutaneous retrograde endovascular occlusion for pediatric varicocele. J Pediatr Surg. 2011;46(3):525-9. PMID: 21376204

BACKGROUND/PURPOSE: The aim of this study was to assess whether percutaneous retrograde endovascular occlusion (PREVO) is effective and safe for the treatment of varicocele in pediatric patients.

METHODS: We retrospectively studied 71 children who underwent PREVO for left-sided varicocele. The primary outcome was the proportion of varicocele-free patients 6 months after PREVO as assessed by ultrasonography.

RESULTS: Seventy-one boys with left-sided grade III varicocele underwent PREVO at a mean age of 13.2 years. PREVO was performed under local anesthesia in all boys but 2, who required general anesthesia. The procedure was technically feasible in 68 (96%) patients. In the remaining 3 patients, the internal spermatic vein could not be catheterized. Minor short-term complications occurred in 6 patients and resolved fully. No major complications or deaths were recorded. The proportion of varicocele-free patients 6 months after PREVO was 93% (66/71) overall and 97% (66/68) in the patients whose PREVO procedure was feasible. No clinical recurrence was observed during the mean follow-up of 17.5 months.

CONCLUSIONS: Percutaneous retrograde endovascular occlusion is an effective minimally invasive approach for varicocele treatment in pediatric patients. It can be safely performed on an outpatient basis under local anesthesia.

18. Condie J, Shaibani A, Wainwright MS. Successful Treatment of Recurrent Basilar Artery Occlusion with Intra-Arterial Thrombolysis and Vertebral Artery Coiling in a Child. Neurocrit Care. 2011. PMID: 21732156

BACKGROUND: Signs of brainstem ischemia in children may be subtle, and outcome following basilar artery occlusion is often poor. There currently are no guidelines in children regarding the best methods to diagnose and treat basilar artery occlusion.

METHODS: Case report and literature review.

RESULTS: We describe the presentation and management of recurrent basilar artery occlusion in a previously healthy 5-year-old boy with vertebral artery dissection. Treatment included emergent intra-arterial tPA and mechanical thrombolysis of basilar artery clot, followed by later coiling of the vertebral artery to prevent recurring episodes of basilar artery ischemia.

CONCLUSION: Management of brainstem stroke in children requires coordination of neurology, critical care, and interventional radiology services. Delayed intra-arterial thrombolysis and vertebral artery coiling can be successfully used to treat basilar artery occlusion and prevent the recurrence of brainstem ischemia in children.

19. Gandolfo C. Giant vertebrobasilar aneurysm in a child: a challenging management. Neuroradiology. 2011. PMID: 21789601

20. Amlie-Lefond C, Zaidat OO, Lew SM. Moyamoya disease in early infancy: case report and literature review. Pediatr Neurol. 2011;44(4):299-302. PMID: 21397174

Moyamoya disease is a progressive, occlusive, cerebrovascular arteriopathy, characterized by bilateral stenosis of the distal internal carotid arteries or branches, with the development of compensatory collateral vessels. It is infrequently reported during infancy. We describe a 2-month-old boy presenting with stroke secondary to moyamoya disease, successfully treated with revascularization surgery at age 3 months. To our knowledge, this report represents the youngest such patient. This case and a review of the literature regarding moyamoya disease during infancy suggest that these patients are at significant risk for further ischemic events and respond well to prompt revascularization surgery.

21. Bracken J, Robinson I, Snow A, Watson R, Irvine AD, Rea D, et al. PHACE syndrome: MRI of intracerebral vascular anomalies and clinical findings in a series of 12 patients. Pediatr Radiol. 2011. PMID: 21674285

BACKGROUND: PHACE (posterior fossa defects, haemangioma, arterial anomalies, coarctation of the aorta and cardiac defects, eye abnormalities) syndrome describes a constellation of abnormalities that can occur in association with segmental craniofacial infantile haemangioma.

OBJECTIVE: To report the spectrum of clinical and imaging abnormalities seen in a cohort of children.

MATERIALS AND METHODS: A retrospective review of the clinical and imaging records of all patients diagnosed with PHACE syndrome between 1998 and 2009 was performed. Information sought included patient demographics, craniofacial segments involved, imaging findings and other extracutaneous abnormalities.

RESULTS: Twelve patients were diagnosed with PHACE syndrome over 11 years. All patients had a segmental craniofacial haemangioma. Involved facial segments, in order of frequency, were frontotemporal (12), maxillary (8), mandibular (5) and frontonasal (1). The most common extracutaneous abnormalities were neurovascular anomalies (10), with many patients having multiple anomalies. The spectrum of arterial anomalies ranged from hypoplasia (9) to ectasia (3), anomalous origin/course (2) and persistent fetal anastomosis (2). Other anomalies found included cardiac anomalies (3), coarctation of the aorta (2), posterior fossa malformations (1) and sternal region anomalies (1).

CONCLUSION: Intracranial anomalies are the most common extracutaneous feature of PHACE syndrome. The contribution of the radiologist in the recognition of such anomalies is important for the diagnosis of PHACE syndrome.

22. Huang MP, Liang CH, Zhao ZJ, Liu H, Li JL, Zhang JE, et al. Evaluation of image quality and radiation dose at prospective ECG-triggered axial 256-slice multi-detector CT in infants with congenital heart disease. Pediatr Radiol. 2011;41(7):858-66. PMID: 21534003

BACKGROUND: There are a limited number of reports on the technical and clinical feasibility of prospective electrocardiogram (ECG)-gated multi-detector computed tomography (MDCT) in infants with congenital heart disease (CHD).

OBJECTIVE: To evaluate image quality and radiation dose at weight-based low-dose prospectively gated 256-slice MDCT angiography in infants with CHD.

MATERIALS AND METHODS: From November 2009 to February 2010, 64 consecutive infants with CHD referred for pre-operative or post-operative CT were included. All were scanned on a 256-slice MDCT system utilizing a low-dose protocol (80 kVp and 60-120 mAs depending on weight: 60 mAs for </=3 kg, 80 mAs for 3.1-6 kg, 100 mAs for 6.1-10 kg, 120 mAs for 10.1-15 kg).

RESULTS: No serious adverse events were recorded. A total of 174 cardiac deformities, confirmed by surgery or heart catheterization, were studied. The sensitivity of MDCT for cardiac deformities was 97.1%; specificity, 99.4%; accuracy, 95.9%. The mean heart rate during scan was 136.7 +/- 14.9/min (range, 91-160) with a corresponding heart rate variability of 2.8 +/- 2.2/min (range, 0-8). Mean scan length was 115.3 +/- 11.7 mm (range, 93.6-143.3). Mean volume CT dose index, mean dose-length product and effective dose were 2.1 +/- 0.4 mGy (range, 1.5-2.8), 24.7 +/- 5.9 mGy.cm (range, 14.7-35.8) and 1.6 +/- 0.3 mSv (range, 1.1-2.5), respectively. Diagnostic-quality images were achieved in all cases. Satisfactory diagnostic quality for visualization of all/proximal/distal coronary artery segments was achieved in 88.4/98.8/80.0% of the scans.

CONCLUSION: Low-dose prospectively gated axial 256-slice CT angiography is a valuable tool in the routine clinical evaluation of infants with CHD, providing a comprehensive three-dimensional evaluation of the cardiac anatomy, including the coronary arteries.

23. Wen Y, Goo HW. Thrombosed congenital extrahepatic portal vein aneurysm in an infant. Pediatr Radiol. 2011. PMID: 21773795

Extrahepatic portal vein aneurysm is extremely rare in infants. We report an infant with thrombosed congenital extrahepatic portal vein aneurysm demonstrated on US and CT. Follow-up US after 16 months showed complete regression of the portal vein aneurysm.

24. Carnevale FC, de Tarso Machado A, Moreira AM, Dos Santos AC, da Motta-Leal-Filho JM, Suzuki L, et al. Long-term results of the percutaneous transhepatic venoplasty of portal vein stenoses after pediatric liver transplantation. Pediatr Transplant. 2011;15(5):476-81. PMID: 21585632

Carnevale FC, de Tarso Machado A, Moreira AM, dos Santos ACB, da Motta-Leal-Filho JM, Suzuki L, Cerri GG, Tannuri U. Long-term results of the percutaneous transhepatic venoplasty of portal vein stenoses after pediatric liver transplantation. Pediatr Transplantation 2011: 15: 476-481. (c) 2011 John Wiley & Sons A/S. Abstract: This paper has the objective to evaluate retrospectively the long-term results of transhepatic treatment of PV stenoses after pediatric LT. During an eight-yr period, 15 children with PV stenoses underwent PTA with balloon dilation or stent placement in case of PTA failure after LT. Patients’ body weights ranged from 9.3 to 46 kg (mean, 15.5 kg). PV patency was evaluated in the balloon dilation and in the stent placement groups. Technical and clinical successes were achieved in all cases with no complication. Eleven patients (11/15; 73.3%) were successfully treated by single balloon dilation. Four patients (4/15; 26.7%) needed stent placement. One patient was submitted to stent placement during the same procedure because of PTA failure. The other three developed clinical signs of portal hypertension because of PV restenoses two, eight, and twenty-eight months after the first PTA. They had to be submitted to a new procedure with stent placement. The follow-up time ranged from 3 to 8.1 yr (mean, 6.3 yr). In conclusion, transhepatic treatment of PV stenoses after pediatric LT with balloon dilation or stent placement demonstrated to be a safe and effective treatment that results in long-term patency.

25. Hogeling M, Adams S, Wargon O. A Randomized Controlled Trial of Propranolol for Infantile Hemangiomas. Pediatrics. 2011. PMID: 21788220

OBJECTIVE: Propranolol hydrochloride is a safe and effective medication for treating infantile hemangiomas (IHs), with decreases in IH volume, color, and elevation.

METHODS: Forty children between the ages of 9 weeks and 5 years with facial IHs or IHs in sites with the potential for disfigurement were randomly assigned to receive propranolol or placebo oral solution 2 mg/kg per day divided 3 times daily for 6 months. Baseline electrocardiogram, echocardiogram, and laboratory evaluations were performed. Monitoring of heart rate, blood pressure, and blood glucose was performed at each visit. Children younger than 6 months were admitted to the hospital for monitoring after their first dose at weeks 1 and 2. Efficacy was assessed by performing blinded volume measurements at weeks 0, 4, 8, 12, 16, 20, and 24 and blinded investigator scoring of photographs at weeks 0, 12, and 24. Results: IH growth stopped by week 4 in the propranolol group. Significant differences in the percent change in volume were seen between groups, with the largest difference at week 12. Significant decrease in IH redness and elevation occurred in the propranolol group at weeks 12 and 24 (P = .01 and .001, respectively). No significant hypoglycemia, hypotension, or bradycardia occurred. One child discontinued the study because of an upper respiratory tract infection. Other adverse events included bronchiolitis, gastroenteritis, streptococcal infection, cool extremities, dental caries, and sleep disturbance.

CONCLUSION: Propranolol hydrochloride administered orally at 2 mg/kg per day reduced the volume, color, and elevation of focal and segmental IH in infants younger than 6 months and children up to 5 years of age.