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Balloon occlusion of traumatic vertebral arteriovenous fistula
122
Surg Neurol 1983;19:122-5
Balloon Occlusion of Traumatic Vertebral Arteriovenous Fistula F.B. Maroun, M.A. Mangan, G. Cornel, and J.C. Jacob The Divisions of Neurosurgery, Cardiovascular Surgery, and Neurology, and the Department of Radiology, Health Science Complex, St. John's, Newfoundland, Canada
Maroun FB, Mangan MA, Cornel G, Jacob JC. Balloon occlusion of traumatic vertebral arteriovenous fistula. Surg Neurol 1983;19:122-5.
A case of arteriovenous fistula of the vertebral artery following percutaneous angiography is reported. Successful obliteration of the fistula was achieved by an inflated F o g a r r y balloon that was placed during angiographic observation. The vascular dynamics of the fistula permitted a safe, one-stage procedure. Vertebral artery; Balloon occlusion; Angiography; Arteriovenous fistula
KEY WORDS:
Arteriovenous fistulas involving the vertebral arteries are rare [9]. The treatment o f such fistulas remains a surgical challenge. Recent advances in balloon technology provide a new therapeutic approach to such neurovascular pathologic lesions [4,5]. The present case illustrates the treatment o f a fistula with balloon occlusion during which obliteration o f the fistula was carried out in a one-stage surgical procedure.
Case Report A 48-year-old, hypothyroid female was admitted for investigation o f proptosis o f the left eye. Neurologic examination confirmed a moderate degree o f exophthalmos o f the left eye together with minimal limitation of upward gaze, and slight but definite venous congestion of the left fundus. H e r neck was short and thick. Coneview x-ray studies and tomography of the skull showed a large dense osteoma situated in the floor o f the frontal sinus on the left side; underlying the osteoma, an adjoining air cell was demonstrated showing hypertrophic characteristics which were thought to be infringing on the orbital cavity. Cerebral angiography was attempted by direct percutaneous puncture o f the left carotid artery Address reprint requests to: Dr. F.B. Maroun, Wedgewood Medical Centre, St. John's, Newfoundland, Canada A I A 2M7.
© 1983 by Elsevier Science Publishing Co., Inc.
by using an Amplatz needle with overriding catheter No. 18C. The guide wire could not be advanced. Test screening showed extravasation o f the contrast material in the neck. Unfortunately no x-ray film was made to determine the extent of the extravasation from the vessel that was punctured. Angiography via the femoral route was performed a week later, and it revealed no abnormality. Two weeks after the procedure, the patient began to complain of a roaring noise in her head, which was more pronounced at night and in the head-down position. In addition, the noise was also "felt" in the nose, and was markedly enhanced by physical activity. Dizziness and mild unsteadiness o f gait were also experienced. Examination revealed the left exophthalmos to be unchanged, and lid-lag was evident. A harsh bruit was heard in the left side of the neck, face, and eye, with the maximum intensity at the level o f the mid portion of the trapezius muscle. Selective angiographies of the left carotid and left vertebral arteries were performed via the femoral route; the carotid circulation was normal. Anteroposterior and lateral stereoscopic views with magnification, and 8-mm serial films confirmed the presence of a vertebral-venous fistula. The communication was at the level o f the fourth cervical vertebra on the left side between the artery and a radicular vein o f the cervical spinal venous plexus (Figure 1). The contrast medium then passed through the anterior spinal vein complex and through the radicular veins filling the posterior spinal and occipital veins (Figure 2). The caliber of the left vertebral artery was markedly reduced. Angiography o f the right brachial artery showed a normal-sized vertebral artery supplying the right posterior inferior cerebellar artery. Under general anesthesia and with the image intensifier centered on the neck, the left vertebral artery was exposed through a horizontal supraclavicular incision. Two No. 18 Amplatz needle catheters were inserted 3 cm apart into the vertebral artery. The lower one was connected through tubing to a syringe filled with contrast medium. Through the upper needle a No. 5 Fogarty arterial embolectomy catheter was inserted to the level o f the fourth cervical vertebra. Concomitant with re0090-3019/83/020122-04503.00
Vertebral Arteriovenous Fistula
Figure 1. Anteroposterior selective angiogram of the left vertebral artery, which was made via the femoral route: Early filling of the arteriovenous communication is visible at the level of vertebra C-4.
peated injection of contrast medium, the Fogarty balloon was inflated with 1.4 cm 3 of contrast medium placed at the mouth of the fistula. Angiography revealed the complete occlusion of the fistula. With the balloon inflated, the lower end of the Fogarty catheter was tied with 2-0 silk and incorporated with a ligature around the vertebral artery; thus a modified trapping procedure was achieved with proximal ligation of the parent vessel and obliteration of the fistula with the balloon. Her postoperative course was smooth except for numbness of the fourth and fifth fingers of the left hand, which eventually disappeared over a 2-month period. This was most likely due to manipulation of the brachial plexus. Observation 2 years after this procedure showed complete absence of the signs and symptoms produced by the fistula. Serial x-ray studies of the neck demonstrated the gradual deflation of the balloon (Figure 3) at 1, 3, and 6 days after surgery.
Discussion Matas (1893) was the first to describe arteriovenous fistula due to trauma. Since then, and up to 1974, 79 cases have been reported in the literature. Our search to date increases the number to 90. The etiology of such
Surg Neurol 1983;19:122-5
123
fistulas falls into two broad categories: traumatic and congenital. Percutaneous angiography [8,12,13] of the vertebral artery is by far the commonest cause: The presence of both artery and veins in the same bony canal accounts for the occurrence of vertebral fistulas due to percutaneous angiography, which are more frequent than carotid-jugular fistulas. The fistulas usually involve single cerebral arteries, the sites of the fistulas are either at the proximal segment, or at the distal segment during angiography via the atlantooccipital route. Fistulas occurring between the vertebral artery and internal jugular vein are extremely rare [6,15]. Traumatic and congenital fistulas have been reported after neck dissection and also during anterior diskectomy [3]. Spontaneous extracranial vertebral arteriovenous fistulas associated with fibro-muscular dysplasia have been recently reported [11]. Spontaneous closure of small fistulas has been described. Kim et al [7] reported the spontaneous closure of a congenital fistula 4 years after it became symptomatic. Various surgical procedures have been advocated in the treatment of these lesions. The treatment of such fistulas according to the two sites (distral or proximal) is slightly different. Most have in common the traditional principle of distal and proximal control of the vessel. Proximal ligation has proved ineffective. Trapping without embolization carried a high incidence of recurrence, due to opening of collateral channels. Trapping with embolization--at one time commonly used in carotid cavernous fistulas [1] has never been used in the treatment of vertebral fistulas. Direct attack upon the fistula has been effective, but the relative inaccessibility of the second portion of the vertebral artery in the transverse foramina of the cervical vertebrae presents considerable technical problems. Kornmesser and Bergan [8] described what they called a "straight forward one stage operation." This involved the removal of the entire vertebral artery from its bony canal in the transverse foramina before its distal and proximal ligation. The introduction of balloon technology by Serbinenko [14] and Debrun et al [4,5] has revolutionized the treatment of vascular lesions of the brain. The indications for this technique have been recently summarized by Mullan et al [10]. Up to the present there have been 12 cases (including ours) treated with balloon occlusion. Three followed percutaneous angiography, and one followed anterior cervical diskectomy. Eight cases were treated with Fogarty catheters and proximal ligation; three others by detachable balloons, with preservation of the parent vessel; only one case was treated with a Fogarty balloon and trapping procedure (Table 1). Binkley and Wylie [2] used the Fogarty catheter directly placed in the vertebral artery. In our case, we used a similar technique with slight modification using
124
Surg Neurol 1983;19:122-5
Maroun et a!
!i¸ : i~'!~ ~ ~
~
i~
.... ii
i~ii!i~
i !!!!iiiiii
f
i~i'~~;ii~~!!~' I!Z~ ~ ~i~iii ~i~
~ ~;!iIi~ili
B Figure 2. Lateral selective angiogram of the lejt vertebral artery, which was made ~ia the femoral route." The complex venous drainage l~ shown both the earl3 CAJ and late (B~ phases.
~ii!i~!!ii~i~ii!!i'!I i~!!ii!i~!~iii ~i!~i iiL i!iiiiii~
i iiiiilili i! A the Amplatz needle. Debrun's technique [4,5] was done in two stages: The first stage consisted in embolization o f the occipital and ascending cervical arteries feeding the fistula with Bucrylate. The second stage dealt with the mouth o f the fistula by detaching an inflated latex balloon. Debrun's explanation o f the two stages in the order mentioned above is the fact that the first stage embolization is necessary and safe because the embolus (Gelfoam or Bucrylate) will be aspirated downstream towards the fistuala rather than upstream toward the basilar trunk. We think that the treatment depends on the complexity o f the fistula and whether there is a single
or multiple communication between the vertebral artery and the vein. In our case, one single channel was evident, and the fistula was obliterated successfully with no signs of recurrence almost 2 years later. Obviously, the method of choice will remain the detachable balloon with preservation of the parent vessel; however, we would like to emphasize that familiarity and knowledge of manufacturing the detachable balloon is mandatory. Regardless of the type of balloon used (Fogarty, Prolo, Sebrinenko, or Debrun), detailed angiographic studies o f the dynamics of the fistula will guide the neurosurgeon in the selection of the treatment required for a given fistula.
V e r t e b r a l A r t e r i o v e n o u s Fistula
Surg N e u r o l 1983;19:122-5
125
?)
A
B
C Figure 3. Lateral cervical spine views: Fogary balloon containing contrast medium at the site of the fistua/. Gradual deflation over a 6-day period.
5. Debrum G. Treatment of certain intracerebral vascular lesions with releasable balloon catheter in current techniques in operative neurosurgery. In: Schmidek H, Sweet W, eds. Current techniques in operative neurosurgery. New York: Grune & Stratton, 1978:4455.
T a b l e 1. B a l l o o n O c c l u s i o n o f V e r t e b r a l Arteriovenous Fistula Type of fistula
Year 1974 1975 1978 1979 1983
Authors Binkley and Wylie Goodman et al Debrun and Debrun et al Buscalgia and Crowhurst Maroun et al
treatment of cerebral vascular lesions. J Neurosurg 1978;49:63549.
Traumatic
Congenital spontaneous
3 1 1 4 1
--2 ---
6. Goodman SJ, Hasso A, Kirpatric D. Treatment ofvertebrojugular fistula by balloon occlusion. J. Neurosurg 1975;43:362-7. 7. Kim YH, Gilbengerg PL, Duchesneal PM. Angiographic evidence of spontaneous closure of nontraumatic arteriovenous fistula of the vertebral artery. J Neurosurg 1973;38:658-6l. 8. Kornmesser TW, Bergan JJ. Anatomic control of vertebral arteriovenous fistulas. Surgery 1974;75:80-6. 9. Lape LL, Palacios E. Acute traumatic vertebral arteriovenous fistula. Ann Surg 1971;174:908-10. 10. Mullan S, Duda EE, Patronas NJ. Some examples of balloon technology in neurosurgery. J Neurosurg 1980;52:32 l - 9 .
References 1. Benati A, Maschio A, Perinis, Beltramelo A. Treatment of posttraumatic carotid cavernous fistula using a detachable balloon catheter. J Neurosurg 1980;53:784-6. 2. Binkley FM, Wylie EG. A new technique for obliteration ofcerebrovascular arteriovenous fistulae. Arch Surg 106:524-7. 3. Buscaglia LC, Crowhurst HD. Vertebral artery trauma. Am J Surg 1979;138:269-72. 4. Debrun G, Lacour P, Caron JP, Hurth M, Comoy J, Keravel Y. Detachable balloon and calibrated leak balloon techniques in the
11. Ramana Reddy SV, Kaznes WE, Earnest F, Sundit TM. Spontaneous extracranial vertebral arteriovenous fistula with fibromuscular dysplasia. J Neurosurg 1981 ;54:399-402. 12. Rossi P, Cazillo FJ, Alfidi RJ, Ruzicka FF. latrogenic arteriovenous fistulas. Diagn Radiol 1974;3:47-51. 13. Sangruchi V, Hitchcock E, Donaldson AA. Post angiographic vertebral arteriovenous fistulae. BrJ Surg 1972;59:627-8. 14. Serbinenko FA. Balloon catheterization and occlusion of major cerebral vessels. J Neurosurg 1974;4 l : 125-45. 15. Suen JY, Boellner SW, Araoz CA, Boop WC. Congenital arteriovenous fistual of the vertebral artery and internal jugular vein. J Pediatr 1972;80:837-8.
Surg Neurol 1983;19:122-5
Balloon Occlusion of Traumatic Vertebral Arteriovenous Fistula F.B. Maroun, M.A. Mangan, G. Cornel, and J.C. Jacob The Divisions of Neurosurgery, Cardiovascular Surgery, and Neurology, and the Department of Radiology, Health Science Complex, St. John's, Newfoundland, Canada
Maroun FB, Mangan MA, Cornel G, Jacob JC. Balloon occlusion of traumatic vertebral arteriovenous fistula. Surg Neurol 1983;19:122-5.
A case of arteriovenous fistula of the vertebral artery following percutaneous angiography is reported. Successful obliteration of the fistula was achieved by an inflated F o g a r r y balloon that was placed during angiographic observation. The vascular dynamics of the fistula permitted a safe, one-stage procedure. Vertebral artery; Balloon occlusion; Angiography; Arteriovenous fistula
KEY WORDS:
Arteriovenous fistulas involving the vertebral arteries are rare [9]. The treatment o f such fistulas remains a surgical challenge. Recent advances in balloon technology provide a new therapeutic approach to such neurovascular pathologic lesions [4,5]. The present case illustrates the treatment o f a fistula with balloon occlusion during which obliteration o f the fistula was carried out in a one-stage surgical procedure.
Case Report A 48-year-old, hypothyroid female was admitted for investigation o f proptosis o f the left eye. Neurologic examination confirmed a moderate degree o f exophthalmos o f the left eye together with minimal limitation of upward gaze, and slight but definite venous congestion of the left fundus. H e r neck was short and thick. Coneview x-ray studies and tomography of the skull showed a large dense osteoma situated in the floor o f the frontal sinus on the left side; underlying the osteoma, an adjoining air cell was demonstrated showing hypertrophic characteristics which were thought to be infringing on the orbital cavity. Cerebral angiography was attempted by direct percutaneous puncture o f the left carotid artery Address reprint requests to: Dr. F.B. Maroun, Wedgewood Medical Centre, St. John's, Newfoundland, Canada A I A 2M7.
© 1983 by Elsevier Science Publishing Co., Inc.
by using an Amplatz needle with overriding catheter No. 18C. The guide wire could not be advanced. Test screening showed extravasation o f the contrast material in the neck. Unfortunately no x-ray film was made to determine the extent of the extravasation from the vessel that was punctured. Angiography via the femoral route was performed a week later, and it revealed no abnormality. Two weeks after the procedure, the patient began to complain of a roaring noise in her head, which was more pronounced at night and in the head-down position. In addition, the noise was also "felt" in the nose, and was markedly enhanced by physical activity. Dizziness and mild unsteadiness o f gait were also experienced. Examination revealed the left exophthalmos to be unchanged, and lid-lag was evident. A harsh bruit was heard in the left side of the neck, face, and eye, with the maximum intensity at the level o f the mid portion of the trapezius muscle. Selective angiographies of the left carotid and left vertebral arteries were performed via the femoral route; the carotid circulation was normal. Anteroposterior and lateral stereoscopic views with magnification, and 8-mm serial films confirmed the presence of a vertebral-venous fistula. The communication was at the level o f the fourth cervical vertebra on the left side between the artery and a radicular vein o f the cervical spinal venous plexus (Figure 1). The contrast medium then passed through the anterior spinal vein complex and through the radicular veins filling the posterior spinal and occipital veins (Figure 2). The caliber of the left vertebral artery was markedly reduced. Angiography o f the right brachial artery showed a normal-sized vertebral artery supplying the right posterior inferior cerebellar artery. Under general anesthesia and with the image intensifier centered on the neck, the left vertebral artery was exposed through a horizontal supraclavicular incision. Two No. 18 Amplatz needle catheters were inserted 3 cm apart into the vertebral artery. The lower one was connected through tubing to a syringe filled with contrast medium. Through the upper needle a No. 5 Fogarty arterial embolectomy catheter was inserted to the level o f the fourth cervical vertebra. Concomitant with re0090-3019/83/020122-04503.00
Vertebral Arteriovenous Fistula
Figure 1. Anteroposterior selective angiogram of the left vertebral artery, which was made via the femoral route: Early filling of the arteriovenous communication is visible at the level of vertebra C-4.
peated injection of contrast medium, the Fogarty balloon was inflated with 1.4 cm 3 of contrast medium placed at the mouth of the fistula. Angiography revealed the complete occlusion of the fistula. With the balloon inflated, the lower end of the Fogarty catheter was tied with 2-0 silk and incorporated with a ligature around the vertebral artery; thus a modified trapping procedure was achieved with proximal ligation of the parent vessel and obliteration of the fistula with the balloon. Her postoperative course was smooth except for numbness of the fourth and fifth fingers of the left hand, which eventually disappeared over a 2-month period. This was most likely due to manipulation of the brachial plexus. Observation 2 years after this procedure showed complete absence of the signs and symptoms produced by the fistula. Serial x-ray studies of the neck demonstrated the gradual deflation of the balloon (Figure 3) at 1, 3, and 6 days after surgery.
Discussion Matas (1893) was the first to describe arteriovenous fistula due to trauma. Since then, and up to 1974, 79 cases have been reported in the literature. Our search to date increases the number to 90. The etiology of such
Surg Neurol 1983;19:122-5
123
fistulas falls into two broad categories: traumatic and congenital. Percutaneous angiography [8,12,13] of the vertebral artery is by far the commonest cause: The presence of both artery and veins in the same bony canal accounts for the occurrence of vertebral fistulas due to percutaneous angiography, which are more frequent than carotid-jugular fistulas. The fistulas usually involve single cerebral arteries, the sites of the fistulas are either at the proximal segment, or at the distal segment during angiography via the atlantooccipital route. Fistulas occurring between the vertebral artery and internal jugular vein are extremely rare [6,15]. Traumatic and congenital fistulas have been reported after neck dissection and also during anterior diskectomy [3]. Spontaneous extracranial vertebral arteriovenous fistulas associated with fibro-muscular dysplasia have been recently reported [11]. Spontaneous closure of small fistulas has been described. Kim et al [7] reported the spontaneous closure of a congenital fistula 4 years after it became symptomatic. Various surgical procedures have been advocated in the treatment of these lesions. The treatment of such fistulas according to the two sites (distral or proximal) is slightly different. Most have in common the traditional principle of distal and proximal control of the vessel. Proximal ligation has proved ineffective. Trapping without embolization carried a high incidence of recurrence, due to opening of collateral channels. Trapping with embolization--at one time commonly used in carotid cavernous fistulas [1] has never been used in the treatment of vertebral fistulas. Direct attack upon the fistula has been effective, but the relative inaccessibility of the second portion of the vertebral artery in the transverse foramina of the cervical vertebrae presents considerable technical problems. Kornmesser and Bergan [8] described what they called a "straight forward one stage operation." This involved the removal of the entire vertebral artery from its bony canal in the transverse foramina before its distal and proximal ligation. The introduction of balloon technology by Serbinenko [14] and Debrun et al [4,5] has revolutionized the treatment of vascular lesions of the brain. The indications for this technique have been recently summarized by Mullan et al [10]. Up to the present there have been 12 cases (including ours) treated with balloon occlusion. Three followed percutaneous angiography, and one followed anterior cervical diskectomy. Eight cases were treated with Fogarty catheters and proximal ligation; three others by detachable balloons, with preservation of the parent vessel; only one case was treated with a Fogarty balloon and trapping procedure (Table 1). Binkley and Wylie [2] used the Fogarty catheter directly placed in the vertebral artery. In our case, we used a similar technique with slight modification using
124
Surg Neurol 1983;19:122-5
Maroun et a!
!i¸ : i~'!~ ~ ~
~
i~
.... ii
i~ii!i~
i !!!!iiiiii
f
i~i'~~;ii~~!!~' I!Z~ ~ ~i~iii ~i~
~ ~;!iIi~ili
B Figure 2. Lateral selective angiogram of the lejt vertebral artery, which was made ~ia the femoral route." The complex venous drainage l~ shown both the earl3 CAJ and late (B~ phases.
~ii!i~!!ii~i~ii!!i'!I i~!!ii!i~!~iii ~i!~i iiL i!iiiiii~
i iiiiilili i! A the Amplatz needle. Debrun's technique [4,5] was done in two stages: The first stage consisted in embolization o f the occipital and ascending cervical arteries feeding the fistula with Bucrylate. The second stage dealt with the mouth o f the fistula by detaching an inflated latex balloon. Debrun's explanation o f the two stages in the order mentioned above is the fact that the first stage embolization is necessary and safe because the embolus (Gelfoam or Bucrylate) will be aspirated downstream towards the fistuala rather than upstream toward the basilar trunk. We think that the treatment depends on the complexity o f the fistula and whether there is a single
or multiple communication between the vertebral artery and the vein. In our case, one single channel was evident, and the fistula was obliterated successfully with no signs of recurrence almost 2 years later. Obviously, the method of choice will remain the detachable balloon with preservation of the parent vessel; however, we would like to emphasize that familiarity and knowledge of manufacturing the detachable balloon is mandatory. Regardless of the type of balloon used (Fogarty, Prolo, Sebrinenko, or Debrun), detailed angiographic studies o f the dynamics of the fistula will guide the neurosurgeon in the selection of the treatment required for a given fistula.
V e r t e b r a l A r t e r i o v e n o u s Fistula
Surg N e u r o l 1983;19:122-5
125
?)
A
B
C Figure 3. Lateral cervical spine views: Fogary balloon containing contrast medium at the site of the fistua/. Gradual deflation over a 6-day period.
5. Debrum G. Treatment of certain intracerebral vascular lesions with releasable balloon catheter in current techniques in operative neurosurgery. In: Schmidek H, Sweet W, eds. Current techniques in operative neurosurgery. New York: Grune & Stratton, 1978:4455.
T a b l e 1. B a l l o o n O c c l u s i o n o f V e r t e b r a l Arteriovenous Fistula Type of fistula
Year 1974 1975 1978 1979 1983
Authors Binkley and Wylie Goodman et al Debrun and Debrun et al Buscalgia and Crowhurst Maroun et al
treatment of cerebral vascular lesions. J Neurosurg 1978;49:63549.
Traumatic
Congenital spontaneous
3 1 1 4 1
--2 ---
6. Goodman SJ, Hasso A, Kirpatric D. Treatment ofvertebrojugular fistula by balloon occlusion. J. Neurosurg 1975;43:362-7. 7. Kim YH, Gilbengerg PL, Duchesneal PM. Angiographic evidence of spontaneous closure of nontraumatic arteriovenous fistula of the vertebral artery. J Neurosurg 1973;38:658-6l. 8. Kornmesser TW, Bergan JJ. Anatomic control of vertebral arteriovenous fistulas. Surgery 1974;75:80-6. 9. Lape LL, Palacios E. Acute traumatic vertebral arteriovenous fistula. Ann Surg 1971;174:908-10. 10. Mullan S, Duda EE, Patronas NJ. Some examples of balloon technology in neurosurgery. J Neurosurg 1980;52:32 l - 9 .
References 1. Benati A, Maschio A, Perinis, Beltramelo A. Treatment of posttraumatic carotid cavernous fistula using a detachable balloon catheter. J Neurosurg 1980;53:784-6. 2. Binkley FM, Wylie EG. A new technique for obliteration ofcerebrovascular arteriovenous fistulae. Arch Surg 106:524-7. 3. Buscaglia LC, Crowhurst HD. Vertebral artery trauma. Am J Surg 1979;138:269-72. 4. Debrun G, Lacour P, Caron JP, Hurth M, Comoy J, Keravel Y. Detachable balloon and calibrated leak balloon techniques in the
11. Ramana Reddy SV, Kaznes WE, Earnest F, Sundit TM. Spontaneous extracranial vertebral arteriovenous fistula with fibromuscular dysplasia. J Neurosurg 1981 ;54:399-402. 12. Rossi P, Cazillo FJ, Alfidi RJ, Ruzicka FF. latrogenic arteriovenous fistulas. Diagn Radiol 1974;3:47-51. 13. Sangruchi V, Hitchcock E, Donaldson AA. Post angiographic vertebral arteriovenous fistulae. BrJ Surg 1972;59:627-8. 14. Serbinenko FA. Balloon catheterization and occlusion of major cerebral vessels. J Neurosurg 1974;4 l : 125-45. 15. Suen JY, Boellner SW, Araoz CA, Boop WC. Congenital arteriovenous fistual of the vertebral artery and internal jugular vein. J Pediatr 1972;80:837-8.