Value of magnetic resonance imaging indices of left renal vein entrapment in the diagnosis of nutcracker syndrome in children

Ren Wang; Meiqiu Wang; Zhengkun Xia; Chunlin Gao; Qianhuining Kuang; Xiang Fang; Min Yu; Yinchao Peng; Xiaojie Li; Yaqin Wei; Tao Ju

doi:10.21037/tp-20-466

Value of magnetic resonance imaging indices of left renal vein entrapment in the diagnosis of nutcracker syndrome in children

Transl Pediatr. 2021 May;10(5):1285-1293. doi: 10.21037/tp-20-466.

Authors

Ren Wang¹, Meiqiu Wang², Zhengkun Xia³, Chunlin Gao³, Qianhuining Kuang¹, Xiang Fang³, Min Yu¹, Yinchao Peng², Xiaojie Li⁴, Yaqin Wei³, Tao Ju¹

Affiliations

¹ Department of Pediatrics, Jinling Hospital, Nanjing Medical University, Nanjing, China.
² Department of Pediatrics, Jinling Hospital, The First School of Clinical Medicine, Southern Medical University, Nanjing, China.
³ Department of Pediatrics, Jinling Hospital, Nanjing University, School Medical, Nanjing, China.
⁴ Department of Pediatrics, Affiliated Jinling Hospital, Medical School of Nanjing University, China.

Abstract

Background: Nutcracker syndrome (NCS) is also known as left renal vein (LRV) compression syndrome. Magnetic resonance imaging (MRI) can better depict the anatomical structure of soft tissues in the area of compression. Diagnosis of NCS using MRI in adults is not uncommon. However, there are few studies on the diagnosis of NCS using MRI in children. Therefore, we conducted this study to evaluate the clinical value of the MRI indices of the LRV in the diagnosis of NCS in children.

Methods: This study was a single-center retrospective analysis. One hundred seventy-four patients with suspected NCS were enrolled from January 2017 to July 2020. The inclusion criteria for suspected NCS were mainly based on clinical symptoms or signs, laboratory examinations and imaging reports. Other diseases that may cause hematuria and/or proteinuria were excluded. We grouped the patients based on the diagnostic criteria for NCS into a nutcracker group and a control group. The receiver operating characteristic (ROC) curve was constructed for evaluating the value of MRI indices in the diagnosis of NCS.

Results: The majority of NCS patients presented with orthostatic proteinuria (OP) (67.2%), followed by hematuria (55.2%), abdominal pain (19.0%), and left flank pain (15.5%). The areas under the curve (AUCs) for the superior mesenteric artery (SMA) angle, beak sign, and compression ratio (CR) in the diagnosis of NCS were 0.870, 0.895, and 0.878, respectively, and the best cutoff values of the SMA angle and CR were 36.8 and 3.99, respectively. The specificities of SMA angle <36.8°, beak sign, CR >3.99, SMA angle <36.8° and beak sign, SMA angle <36.8° and CR >3.99, and beak sign and CR >3.99 were 82.5%, 93.8%, 93.8%, 97.9%, 95.9% and 97.9%, respectively.

Conclusions: Children with SMA angles less than 36.8°, beak signs and CR greater than 3.99 should be highly suspected of having NCS. Among these parameters, "beak sign" showed the highest diagnostic accuracy by MRI, and the combination of any two of the above parameters achieved a higher specificity than the single parameters.

Keywords: Nutcracker syndrome (NCS); children; left renal vein (LRV); magnetic resonance imaging (MRI).