Female conjoined throraco-omphalopagus twins were delivered via cesarean section at 35 weeks 5 days gestational age to a 38-year-old mother who received standard prenatal care. After resuscitation, the twins were transferred to the neonatal ICU, where they remained for monitoring and growth as they were assessed for potential separation. CT angiography was performed at 3-4 months of life using a staged approach. Selective IV and oral contrast administration was used over two visits to delineate shared and non-shared structures. Most significantly, there was a single shared liver with anomalous hepatic venous drainage. Twin A had three normal caliber hepatic veins draining into a normal IVC, but a large branch of the middle hepatic vein traversed midline into Twin B and received hepatic venous drainage from Twin B via numerous anomalous vessels. Twin B had a normal IVC but three diminutive hepatic veins, thought to be due to reduced venous drainage as a result of the anomalous shared vasculature. After multidisciplinary discussion, interventional radiology was consulted for hepatic venogram and intervention as needed. The anomalous communicating vessels were identified on hepatic venogram via Twin A femoral approach. Occlusion of the anomalous branches was achieved with serial embolization of the primary draining vessel on the Twin A side using Amplatzer vascular plugs. Successful occlusion was confirmed on venography after the final embolization procedure. Follow-up Doppler ultrasound exams confirmed improved hepatic venous outflow in Twin B, initially with reversal of flow in the anomalous veins back toward the IVC of Twin B, followed by nonvisualization of the anomalous veins on later exams. CT angiography later showed enlarged caliber of the native Twin B hepatic veins. Following the optimization of hepatic venous outflow, the multispecialty surgical team proceeded with separation. The twins were separated at 13 months of age without complication. In addition to restoring venous outflow to allow for a successful surgical outcome, it was noted that the Amplatzer devices were used as surgical landmarks during separation for identification of shared anatomy. Through careful planning and execution, diagnostic and interventional radiology techniques played a critical role in this successful outcome. Read More

Meeting name: SPR 2019 Annual Meeting & Postgraduate Course , 2019

Authors: Yen Christopher, Kukreja Kamlesh, Masand Prakash

Keywords: Conjoined twins, Interventional Radiology, CT Angiography

1) Reviewing the pathology and outcomes of children with spinal muscular atrophy (SMA) 2) Learning the procedures available for intrathecal access 3) Understanding the indications for choosing more advanced techniques to deliver nusinersen Spinal muscular atrophy is an autosomal recessive disease affecting motor neurons and is the most common genetic cause of death in infants. Nuinersen (Spinraza) was recently approved by FDA for intrathecal administration in SMA patients. Commonly administered by lumbar puncture in the clinic or with imaging guidance, this is the initial method of administering nusinersen. Deformities and spinal instrumentation from orthopedic surgeries are common in SMA patients, preventing traditional intrathecal access by lumbar puncture for nusinersen delivery. Transforaminal lumbar sac access, ultrasound or fluoroscopy guided cervical spine access, or subcutaneous catheter placement can be the alternative approaches with failed/difficult lumbar access. Given the potential benefit of nusinersen, understanding all methods to obtain intrathecal access is essential for a pediatric interventional radiology (IR) practice. Read More

Meeting name: SPR 2019 Annual Meeting & Postgraduate Course , 2019

Authors: Ortiz Carlos, Chau Alex, Desai Sudhen, Kukreja Kamlesh

Keywords: nusinersen, spinal muscular atrophy, intrathecal administration

Bone biopsy for histopathology and tissue culture remains the gold standard for diagnosis of osteomyelitis. However, MRI often results in a radiologic diagnosis of osteomyelitis preceding biopsy. The purpose of this study is to examine the diagnostic yield of percutaneous bone biopsies and the effect of biopsy results on clinical management in children with suspected osteomyelitis and positive MRI findings. Read More

Meeting name: SPR 2020 Annual Meeting & Postgraduate Course , 2020

Authors: Yen Christopher, Hernandez Alberto, Gardner Gregory, Nazario Maricarmen, Kukreja Kamlesh, Desai Sudhen

Keywords: Biopsy, Osteomyelitis, MRI