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{"target":"https://pubannotation.org/docs/sourcedb/PMC/sourceid/4134656","sourcedb":"PMC","sourceid":"4134656","source_url":"https://www.ncbi.nlm.nih.gov/pmc/4134656","text":"Pre-treatment evaluation\nMost cases of IH can be diagnosed clinically, but imaging studies (MRI, Doppler ultrasound) or tissue biopsy may be required in doubtful cases. Additional investigations may be required depending upon the site(s) and extent of involvement.\nSegmental hemangiomas may be associated with visceral hemangiomatosis, with the location of visceral lesions often correlating with the site of cutaneous involvement. Infants with large segmental hemangiomas on the face are at risk for PHACES syndrome (Posterior fossa anomalies, Haemangiomas, Arterial anomalies, Coarctation of aorta and Cardiac defects, Eye abnormalities, Sternal clefting and Supra-umbilical raphe) and should undergo a thorough ophthalmological, cardiac and neurological evaluation. Magnetic resonance imaging (MRI) with angiography of the head and neck region is usually indicated in such infants.[8910] Similar to PHACES syndrome, segmental hemangiomas in the perineal region may be associated with malformations of the urogenital or anogenital systems; these include SACRAL (spinal dysraphism, anogenital, cutaneous, renal and urologic anomalies, associated with an angioma of lumbosacral localisation) and PELVIS (perineal haemangioma, external genitalia malformations, lipomyelomeningocele, vesicorenal abnormalities, imperforate anus and skin tag) syndrome. Haemangiomas on the lumbosacral region may be a marker of occult spinal dysraphism. A spinal MRI is indicated as a screening test for all cases with lumbosacral haemangiomas.[11] Laryngeal involvement can occur if haemangiomas are present on the cervicofacial, mandibular or the ‘beard’ distribution. Affected infants should be watched for signs and symptoms of airway obstruction (stridor, hoarseness) and referred for a laryngeal examination.[12] Infants with multiple cutaneous haemangiomas (diffuse neonatal haemangiomatosis) constitute another group which is at risk for visceral involvement, and it is generally recommended to screen the patient for hepatic involvement by abdominal ultrasound.[1314] Raised levels of iodothyronine deiodinase have been demonstrated in large proliferative haemangiomas, which can lead to hypothyroidism. Till date, most of the cases of hypothyroidism have been noted in association with hepatic haemangiomatosis, though increased iodothyronine deiodinase activity has been detected in some large cutaneous lesions as well. Hence, a recommendation has been made to perform serial thyroid function tests in patients with hepatic haemangiomatosis or large cutaneous haemangiomas.[1516]\nOnce a decision has been made to treat the haemangioma, pre-treatment investigations should be tailored to the chosen therapeutic modality. Before initiating propranolol therapy, the children need to be assessed for the following contraindications: bronchial asthma, heart failure, sinus bradycardia, hypoglycaemia, hypotension, heart block and known allergy to propranolol. The initial examination should include a thorough cardiopulmonary assessment including pulse rate, blood pressure and blood sugar. A baseline electrocardiogram (ECG) is usually recommended. Although echocardiography is not a routine investigation, it may be required to exclude functional and structural heart diseases.[7] The pre-treatment work-up before starting steroid therapy include ruling out active infection or primary immunodeficiency disease, (complete blood count with differential leucocyte count, serum biochemistry, chest x-ray and urine and stool microscopy), and a baseline anthropometric examination (height, weight) and blood pressure, which should be monitored serially.","divisions":[{"label":"title","span":{"begin":0,"end":24}},{"label":"p","span":{"begin":25,"end":264}},{"label":"p","span":{"begin":265,"end":2571}}],"tracks":[{"project":"2_test","denotations":[{"id":"25136206-14758450-58659525","span":{"begin":885,"end":886},"obj":"14758450"},{"id":"25136206-9609880-58659526","span":{"begin":885,"end":887},"obj":"9609880"},{"id":"25136206-16510684-58659527","span":{"begin":885,"end":889},"obj":"16510684"},{"id":"25136206-9386676-58659528","span":{"begin":1525,"end":1527},"obj":"9386676"},{"id":"25136206-20828712-58659529","span":{"begin":1795,"end":1797},"obj":"20828712"},{"id":"25136206-19159729-58659530","span":{"begin":2051,"end":2053},"obj":"19159729"},{"id":"25136206-22244411-58659531","span":{"begin":2051,"end":2055},"obj":"22244411"},{"id":"25136206-10900278-58659532","span":{"begin":2566,"end":2568},"obj":"10900278"},{"id":"25136206-14654623-58659533","span":{"begin":2566,"end":2570},"obj":"14654623"},{"id":"25136206-23266923-58659534","span":{"begin":3267,"end":3268},"obj":"23266923"}],"attributes":[{"subj":"25136206-14758450-58659525","pred":"source","obj":"2_test"},{"subj":"25136206-9609880-58659526","pred":"source","obj":"2_test"},{"subj":"25136206-16510684-58659527","pred":"source","obj":"2_test"},{"subj":"25136206-9386676-58659528","pred":"source","obj":"2_test"},{"subj":"25136206-20828712-58659529","pred":"source","obj":"2_test"},{"subj":"25136206-19159729-58659530","pred":"source","obj":"2_test"},{"subj":"25136206-22244411-58659531","pred":"source","obj":"2_test"},{"subj":"25136206-10900278-58659532","pred":"source","obj":"2_test"},{"subj":"25136206-14654623-58659533","pred":"source","obj":"2_test"},{"subj":"25136206-23266923-58659534","pred":"source","obj":"2_test"}]}],"config":{"attribute types":[{"pred":"source","value type":"selection","values":[{"id":"2_test","color":"#93abec","default":true}]}]}}