Application of the #Enzian classification for endometriosis on MRI: prospective evaluation of inter- and intraobserver agreement.

Objectives: The purpose of this investigation was to evaluate the inter- and intraobserver variability of the updated #Enzian classification of endometriosis on MRI and to evaluate the influence of reader experience on interobserver concordance. Methods: This was a prospective single-center study. All patients were included who received an MRI of the pelvis for evaluation of endometriosis between March and July 2023 and who have provided written informed consent. Images were reviewed independently for endometriosis by three radiologists, utilizing the MRI-applicable categories of the #Enzian classification. Two radiologists had experience in pelvic MRI and endometriosis imaging. One radiologist had no specific experience in pelvic MRI and received a one-hour briefing beforehand. Results: Fifty consecutive patients (mean age, 34.9 years ±8.6 [standard deviation]) were prospectively evaluated. Interobserver agreement was excellent for diagnosis of deep infiltrating endometriosis (Fleiss' kappa: 0.89; 95% CI 0.73-1.00; p < 0.001) and endometriomas (Fleiss' kappa: 0.93; 95% CI 0.77-1.00; p < 0.001). For the experienced readers, interobserver agreement in the assessment of compartments A, B and C was excellent (κw ranging from 0.84; 95% CI 0.71-0.97; p < 0.001 to 0.89; 95% CI 0.82-0.97; p < 0.001). For the pairings of the experienced readers to the reader without specific experience in pelvic MRI, agreement was substantial to excellent (κw ranging from 0.64; 95% CI 0.44-0.85; p < 0.001 to 0.91; 95% CI 0.84-0.98; p < 0.001). Intraobserver variability was excellent for compartments A, B and C (κw ranging from 0.85; 95% CI 0.73-0.96; p < 0.001 to 0.95; 95% CI 0.89-1.00; p < 0.001). Conclusion: With sufficient experience, the #Enzian classification enables the achievement of excellent inter- and intraobserver agreement in MRI-based diagnosis of deep infiltrating endometriosis and endometriomas.

Evaluation of diagnostic accuracy of dual-energy computed tomography in patients with chronic thromboembolic pulmonary hypertension compared to V/Q-SPECT and pulmonary angiogram.

Purpose: The relevance of dual-energy computed tomography (DECT) for the detection of chronic thromboembolic pulmonary hypertension (CTEPH) still lies behind V/Q-SPECT in current clinical guidelines. Therefore, our study aimed to assess the diagnostic accuracy of DECT compared to V/Q-SPECT with invasive pulmonary angiogram (PA) serving as the reference standard. Methods: A total of 28 patients (mean age 62.1 years ± 10.6SD; 18 women) with clinically suspected CTEPH were retrospectively included. All patients received DECT with the calculation of iodine maps, V/Q-SPECT, and PA. Results of DECT and V/Q-SPECT were compared, and the percent of agreement, concordance (utilizing Cohen's kappa), and accuracy (kappa2) to PA were calculated. Furthermore, radiation doses were analyzed and compared. Results: In total, 18 patients were diagnosed with CTEPH (mean age 62.4 years ± 11.0SD; 10 women) and 10 patients had other diseases. Compared to PA, accuracy and concordance for DECT were superior to V/Q-SPECT in all patients (88.9% vs. 81.3%; k = 0.764 vs. k = 0.607) and in CTEPH patients (82.4% vs. 70.1%; k = 0.694 vs. k = 0.560). Furthermore, the mean radiation dose was significantly lower for DECT vs. V/Q-SPECT (p = 0.0081). Conclusion: In our patient cohort, DECT is at least equivalent to V/Q-SPECT in diagnosing CTEPH and has the added advantage of significantly lower radiation doses in combination with simultaneous assessment of lung and heart morphology. Hence, DECT should be the subject of ongoing research, and if our results are further confirmed, it should be implemented in future diagnostic PH algorithms at least on par with V/Q-SPECT.

Current Status of Cardiovascular Imaging in Germany: Structured Data from the National Certification Program, ESCR Registry, and Survey among Radiologists.

PURPOSE: In the light of the increasing importance of cardiovascular cross-sectional imaging in current guidelines, the goal of this study is to provide a comprehensive overview of cardiovascular imaging (CVI) offered by radiological institutions across Germany. MATERIALS AND METHODS: Data were extracted from the national certification program database of the German Roentgen Society (DRG) from 2015-2021. A nationwide online survey among radiology institutes (university hospitals, non-university hospitals, and private practices) was conducted for 2019, and data was extracted from the European Society of Cardiovascular Radiology (ESCR) registry. The data collection's key points included the number of centers and individuals certified for CVI, the number of cardiac CT and MRI examinations performed, the reporting habits, and the participation in the ESCR registry. RESULTS: 71 centers and 1278 persons, both with a substantial increase since 2015, were registered and certified by the DRG to perform CVI. According to the survey, a total of 69,286 CT and 64,281 MRI examinations were performed annually. Data from the survey and the ESCR registry indicated that reporting was mostly done solely by radiologists or, to a lesser degree, in joint consensus meetings with non-radiologists. The overall participation rate in the ESCR registry was 48 % among the survey's participants. CONCLUSION: This comprehensive analysis demonstrates that high-quality CVI by radiologists is available nationwide. The current challenges are to provide the best medical and technical quality of CVI by radiology for patient care and to ensure economic sustainability in the German health care system to accommodate the predicted substantial need for CVI in the future. KEY POINTS: · High-quality advanced CVI service by radiologists is available nationwide.. · Highly qualified specialist knowledge is widely represented from university to private practices.. · Certification programs successfully contribute to the dissemination & deepening of CVI expertise.. · The ESCR registry is an established international tool for the documentation of CVI.. CITATION FORMAT: · Sieren M, Maintz D, Gutberlet M et al. Current Status of Cardiovascular Imaging in Germany: Structured Data from the National Certification Program, ESCR Registry, and Survey among Radiologists. Fortschr Röntgenstr 2022; 194: 181 - 191.

Value of Left Ventricular Feature Tracking Strain Analysis for Detection of Early Cardiac Involvement in Fabry Disease (FD).

PURPOSE: Detection of cardiac involvement in Fabry disease (FD) is of high importance for treatment management. Native T1 mapping especially showed great potential for detection of early cardiac manifestations. Echocardiographic studies showed strain abnormalities in FD patients, but data on MRI feature tracking strain analysis (FT-SA) is limited. Therefore, the aim of our study was to evaluate the potential of FT-SA compared to native T1 and the FD specific biomarker Globotriaosylsphingosine (LysoGb3). METHODS: 28 consecutive FD patients (18 female; 47.8 years ± 17.4 standard deviation (SD)) and 28 control subjects (18 female; 46.6 years ± 18.2 SD) underwent cardiac MRI at 1.5 Tesla. Global native T1 times and left ventricular FT-SA were evaluated. Results were correlated to serum Lyso-Gb3-levels. RESULTS: Native T1 times, global longitudinal (GLS) and global radial strain (GRS) were significantly reduced in FD patients (p < 0.0064, p = 0.0009 and p = 0.0184, respectively). Moreover, native T1 times and GLS were significantly lower in Lyso-Gb3 positive FD patients (p < 0.005 and p = 0.03). GLS, native T1 times showed significant moderate correlations to LysoGb3 (p = 0.002 and p < 0.001). Furthermore, GLS and native T1 times reduce when LysoGb3 was elevated and increasingly with presence of left ventricular hypertrophy (LVH) or late gadolinium enhancement (LGE). CONCLUSIONS: Native T1 times and strain values differ significantly between FD patients and control subjects and showed promising correlations to the FD specific biomarker LysoGb3. We therefore conclude that strain abnormalities occur early beside native T1 reductions in cardiac FD involvement. Large scale trials are needed to verify our findings.

Evaluation of Diagnostic Accuracy and Radiation Exposure of Dual-Energy Computed Tomography (DECT) in the Course of Chronic Thromboembolic Pulmonary Hypertension (CTEPH). / Evaluation der diagnostischen Genauigkeit und der Strahlendosis der Dual-Energy-Computertomografie (DECT) bei chronisch thromboembolischer pulmonaler Hypertonie (CTEPH).

PURPOSE: The purpose of this study was to assess the diagnostic accuracy of computed tomography pulmonary angiogram (CTPA) including dual energy and reconstruction of iodine maps for diagnosing CTEPH. This method for detecting embolisms and perfusion failures was compared with V/Q-SPECT. An additional purpose was to compare the applied radiation dose of both techniques. MATERIALS AND METHODS: 71 patients (49 women) with suspected CTEPH were included in this prospective study. The patients received a V/Q-SPECT and a dual-energy CTPA. Iodine maps were reconstructed from the data set. CTPA and the iodine maps were read by an experienced radiologist unaware of the clinical information as well as the results of the V/Q-SPECT. Results were compared to the V/Q-SPECT. DLP and the applied amount of radionuclides (MAA, Technegas) were obtained for comparison of radiation dose. RESULTS: For the diagnosis of CTEPH, the sensitivity of DECT was 1.000, specificity 0.966, PPV 0.867 and NPV 1.000, respectively. There was not a considerable difference in the x-ray exposure between the DECT examination and the V/Q-SPECT (1.892 mSv vs. 1.911 mSv; p = 0.6115). Both examination modalities were highly consistent regarding the classification of pathological segments (1177/1278 segments, 92,09 %, κ = 0,5938). CONCLUSION: This study presents the DECT, in combination with reconstructed iodine maps, as a potential alternative to the current imaging technique of first choice, V/Q-SPECT. For creating future prospective diagnostic algorithms, the implementation of DECT screening with iodine maps should be considered. KEY POINTS: · DECT correctly identified all CTEPH patients.. · There is substantial agreement between DECT and V/Q-SPECT in the classification of pathological segments.. · There is no significant difference in radiation exposure during DECT examination and V/Q-SPECT examination.. · Reduced radiation dose does not negatively impact image quality.. CITATION FORMAT: · Schüßler A, Richter M, Tello K et al. Evaluation der diagnostischen Genauigkeit und der Strahlendosis der Dual-Energy-Computertomografie (DECT) bei chronisch thromboembolischer pulmonaler Hypertonie (CTEPH). Fortschr Röntgenstr 2021; 193: 1318 - 1326.

Optimization of Whole-Body CT Examinations of Polytrauma Patients in Comparison with the Current Diagnostic Reference Levels. / Optimierung von Ganzkörper-CT-Untersuchungen an Polytraumatisierten anhand des Vergleichs mit den aktuellen diagnostischen Referenzwerten.

PURPOSE: Evaluation of the dose values of a polytrauma whole-body CT examination used in clinical practice with regard to the 2016 updated diagnostic reference levels and reduction of the mean exposure levels using simple optimization steps. MATERIALS AND METHODS: In each case, 100 exposure values before and after dose optimization were compared with the old and new diagnostic reference levels. The grayscale values and the signal-to-noise ratio (SNR) were determined for the lung, the aortic arch and the liver. A visual assessment of the image quality was performed by two radiologists on the basis of a Likert scale (0 - non-diagnostic, 1 - poor visualization, 2 - moderate visualization, 3 - good visualization, 4 - excellent visualization) for CT examinations both before and after optimization. RESULTS: The acquired exposure values after dose optimization were below the old and new diagnostic reference levels (1319.98 ±â€Š463.16 mGy ·â€Šcm) while the mean value of the exposure values before optimization (1774.96 ±â€Š608.78 mGy ·â€Šcm) exceeded the current diagnostic reference levels. The measured grayscale values (HU) were (before versus after optimization): lung - 833 HU vs. - 827 HU (p = 0.43), aortic arch 341 HU vs. 343 HU (p = 0.70) and liver 68 HU vs. 67 HU (p = 0.35). After dose optimization the SNR in the lung was minimally higher, while it was minimally lower in the two other regions than before the optimization. Visual assessment of the image quality showed almost identical values with 3.85 evaluation points before and 3.82 evaluation points after dose optimization (p = 0.57). CONCLUSION: Due to the updating of the diagnostic reference levels, an analysis of the own exposure values is necessary in order to be able to detect high values promptly and to initiate appropriate measures for dose reduction. Appropriate adaptation of the examination parameters with consideration of the necessary image quality allows a significant reduction of the radiation exposure in most cases, also on CT devices of older generations. KEY POINTS: · In many cases a dose reduction below the DRLs is already possible by optimizing the examination technique.. · In order to ensure a diagnostic image quality, the control of the image quality is unavoidable in a dose reduction.. · Through suitable parameter adjustments a compliance with the DRLs is also possible, using CT devices of older generation without iterative image reconstruction.. CITATION FORMAT: · Schäfer SB, Rudolph C, Kolodziej M et al. Optimization of Whole-Body CT Examinations of Polytrauma Patients in Comparison with the Current Diagnostic Reference Levels. Fortschr Röntgenstr 2019; 191: 1015 - 1025.

Assessment of Cardiac Involvement in Fabry Disease (FD) with Native T1 Mapping.

PURPOSE: Fabry disease (FD) is an X-linked multi-organ disorder of lysosomal metabolism with cardiac disease being the leading cause of death. Identifying early FD-specific pathologies is important in the context of maximum therapeutic benefit in these stages. Therefore, the aim of this study was to investigate the value of quantitative cardiac T1 mapping as a potential disease-specific surrogate. METHODS: 16 consecutive FD patients (9 female, 7 male; median age: 54 years, IQR 17) and 16 control patients (9 female, 7 male; median age: 52 years, IQR 20) were investigated at 1.5 Tesla. Native T1 mapping was performed using a modified look locker inversion recovery sequence (MOLLI) and native T1 times were measured within the septal myocardium at the midventricular short-axis section. Also functional parameters, left ventricular morphology, presence of late-gadolinium enhancement, cTnI- and Lyso-Gb3-Levels were evaluated. RESULTS: The median native septal T1 time for FD was 889.0 ms and 950.6 ms for controls (p < 0.003). LGE and positive cTnI values (0.26 ±â€Š0.21) were present in 5 FD patients (31.25 %), and left ventricular hypertrophy (LVH) was present in 4 FD patients (25.00 %). The 4 cTnI and 8 Lyso-Gb3 positive FD patients had significantly lower native T1 values (p < 0.05, respectively p < 0.01). Assuming a T1 cut-off value of 900 ms for the identification of increased cardiac lipid deposit, 9 patients with FD (56.25 %) had pathologic values (4 patients cTnI and 8 patients Lyso-Gb3 positive). Moreover, native septal T1 showed a good negative correlation to Lyso-Gb3 (r = - 0.582; p = 0.018). CONCLUSION: A pathologic cardiac native T1 time obviously reflects cardiac involvement in the scope of FD at tissue level. In the future native T1 mapping as an imaging biomarker might allow identification of early stages of cardiac involvement in FD before morphological changes are obvious. KEY POINTS: · Native T1 values are significantly decreased in Fabry disease.. · Native T1 shows promising correlation to cardiac and Fabry-specific biomarkers.. · Native T1 mapping might have great potential for early disease detection and therapy monitoring.. CITATION FORMAT: · Roller FC, Fuest S, Meyer M et al. Assessment of Cardiac Involvement in Fabry Disease (FD) with Native T1 Mapping. Fortschr Röntgenstr 2019; 191: 932 - 939.

Impact of Abdominal Follow-Up Sonography in Trauma Patients Without Abdominal Parenchymal Organ Lesion or Free Intraabdominal Fluid in Whole-Body Computed Tomography.

Purpose Patients suffering from severe blunt abdominal trauma are challenging because of their need for accurate diagnostic imaging and fast therapeutic action. Whole-body computed tomography (WBCT) is highly sensitive and represents the gold standard in the trauma room diagnostic setting. The aim of our study was to investigate the impact and therapy relevance of abdominal follow-up sonography (AFS) as part of the tertiary trauma survey (TTS) in patients without abdominal parenchymal organ lesions or free abdominal fluid in initial WBCT. Materials and Methods All adult patients without abdominal parenchymal organ lesions or free intraabdominal fluid in the initial WBCT examination, who received AFS within 24 hours after trauma, were included in this retrospective analysis between January 2008 and December 2011. Results 316 patients were analyzed (ISS 10 ±â€Š8, NISS 13 ±â€Š11) according to the inclusion criteria. Overall, only small amounts of free intraabdominal fluid were detected in AFS in 3 patients (0.9 %) and remained without therapeutic consequence. None of the patients died due to intraabdominal bleeding. Conclusion AFS as part of the TTS did not show additional benefits and had no impact on further treatment in patients without abdominal parenchymal organ lesions or free intraabdominal fluid in the initial WBCT examination. We conclude that AFS is not routinely required but should be performed if indicated on a clinical or laboratory basis because of its fast and less invasive character. Key points · Seriously injured patients are challenging for medical imaging and treatment.. · Whole-body computed tomography is known for its high accuracy in trauma patients.. · Nonetheless, missed injuries are a major challenge in trauma patients.. · Therefore, follow-up ultrasound is often performed within the tertiary trauma survey.. · Follow-up ultrasound in patients with an inconspicuous abdominal computed tomography scan did not show any benefit.. Citation Format · Schneck E, Koch C, Borgards M et al. Impact of Abdominal Follow-Up Sonography in Trauma Patients Without Abdominal Parenchymal Organ Lesion or Free Intraabdominal Fluid in Whole-Body Computed Tomography. Fortschr Röntgenstr 2017; 189: 128 - 136.

Breast Ultrasonography: Findings in Pediatric Patients.

Purpose To analyze referral indications, imaging findings and diagnoses in breast sonography in a division of pediatric radiology. Materials and Methods Breast ultrasound examinations of 270 patients were analyzed for referral reasons, imaging findings and final diagnoses (152 females, 118 males). The mean age of the patients was 8.8 years (range, 6 days-18 years). Each breast was examined systematically in two orthogonal probe orientations. Pathological findings were documented on two orthogonal imaging planes. Color Doppler ultrasonography was used additionally. Images and clinical data were reviewed in all cases. Results The most frequent referral reasons in female patients were breast enlargement (104 patients), palpable mass (24 patients) and mastodynia (23 patients). The most frequent diagnoses were normal gland tissue (101 patients), cysts (9 patients), augmented adipose tissue (7 patients) and hemangiomas (7 patients). The most frequent referral reasons in male patients were breast enlargement (106 patients), palpable mass (13 patients) and mastodynia (9 patients). The most frequent diagnoses were gland tissue (79 patients), augmented adipose tissue (24 patients) and cysts (10 patients). Only 2 malignant masses were diagnosed: A Burkitt lymphoma and a relapsed ALL. Conclusion Fear of breast cancer and permanent damage to the breast leads to low-threshold medical consultations and referrals. Sensitive handling is required especially in adolescent patients. Most disorders arise due to the variability of breast development. Ultrasound serves as a means to exclude significant diseases of the breast.