Postmortem 3-D reconstruction of skull gunshot injuries.

BACKGROUND: In cases of severe decomposition or skeletonization of a corpse after cerebral gun shot injury it is difficult to exactly reconstruct the bullet path in the brain. However, in case of murder or homicide this might become necessary to answer forensic questions such as the ability to move or other actions of the victim. MATERIALS AND METHODS: Therefore a method in terms of three dimensional reconstruction technique was developed by fusing computed tomography scans (CT) of the original skull and magnetic resonance images (MRI) of a normal brain of adequate size. Hereby five cases were investigated. RESULTS: In three cases an excellent concordance between the reconstructed bullet trajectory and the autopsy reports was achieved. In one case the original brain was not available for CT-scanning due to previous autopsy. However, the findings were in line with the pathology report. In one case there was a difference of about 1-2 cm between the original autopsy description and the reconstructed bullet path. This was due to only a part of the skull being available for image reconstruction. CONCLUSION: The findings suggest that this method can successfully be applied to adequately reconstruct bullet paths in cases of completely skeletonized skulls, but should carefully be used in cases of incomplete skulls.

[Macroscopic and endoscopic examinations of the head and neck region in ancient Egyptian mummies]. / Makroskopische und endoskopische Untersuchung der Kopf-Hals-Region an altägyptischen Mumien.

INTRODUCTION: The examination of mummies has mostly been performed by macroscopic investigation after unwrapping. During the last decades, however, several research groups provided clear evidence that the combination of various noninvasive approaches for the examination of mummies offers distinct advantages over the previously used methods of unwrapping and inspection. Particularly, the introduction of endoscopic techniques has been used for a closer examination of mummies without destroying them. METHODS: In the last 5 years we analysed about 250 mummies and skeletons found in the necropolis of Thebes-West, Upper Egypt, with particular reference to normal and pathological findings in the head and neck region. Beside macroscopic examination we used endoscopes for the inspection of the nasal cavity and the ear. RESULTS: Most individuals revealed normal macroscopic and endoscopic features. In particular, several skulls showed the auditory ossicles in normal anatomic position indicating an excellent conservation of the specimens. Nevertheless, pathological alterations could be detected affecting different regions of the head and neck. In particular, several individuals presented with fractures of the nasal bones. One case even revealed a severe old-healed fracture of the mid-face (type Le Fort III) with complete loss of all teeth, suggesting adequate "therapeutic" treatment of the skull fracture. Further findings, evidenced by endoscopy, were dentogenic sinusitis and chronic middle ear infections with intracranial perforation in one case. In addition, in one case fixation of the stapes suggests the residues of subluxation of the stapes. CONCLUSION: In this study, we provide further evidence that a careful macroscopic and endoscopic investigation of mummy skulls reveals important information on the state of conservation of the study population and may unravel distinct paleopathological diseases of the head and neck region.

Sigmoidorectal intussusception caused by rectal carcinoma: multislice CT findings.

We report a case of an extensive intermittent sigmoidorectal intussusception due to an adenocarcinoma of the rectum in an adult. Abdominal multislice computed tomography with two-dimensional multiplanar reformatted images and three-dimensional volume rendering rapidly established the diagnosis preoperatively. The intussusception was confirmed by surgery.

[[F-18]FDG imaging of head and neck tumors: comparison of hybrid PET, dedicated PET and CT]. / [F-18]FDG-Bildgebung bei Kopf-Hals-Tumoren: vergleichende Untersuchungen mit Hybrid-PET, Ring-PET und CT.

AIM: Aim of the study was to evaluate [F-18]FDG imaging of head and neck tumors using a Hybrid-PET device of the 2nd or 3rd generation. Examinations were compared to dedicated PET and Spiral-CT. METHODS: 54 patients suffering from head and neck tumors were examined using dedicated PET and Hybrid-PET after injection of 185-350 MBq [F-18]FDG. Examinations were carried out on the dedicated PET first followed by a scan on the Hybrid-PET. Dedicated PET was acquired in 3D mode, Hybrid-PET was performed in list mode using an axial filter. Reconstruction of data was performed iteratively on both, dedicated PET and Hybrid-PET. All patients received a CT scan in multislice technique. All finding have been verified by the goldstandard histology or in case of negative histology by follow up. RESULTS: Using dedicated PET the primary or recurrent lesion was correctly diagnosed in 47/48 patients, using Hybrid-PET in 46/48 patients and using CT in 25/48 patients. Metastatic disease in cervical lymph nodes was diagnosed in 17/18 patients with dedicated PET, in 16/18 patients with Hybrid-PET and in 15/18 with CT. False positive results with regard to lymph node metastasis were seen with one patient for dedicated PET and Hybrid-PET, respectively, and with 18 patients for CT. In a total of 11 patients unknown metastatic lesions were seen with dedicated PET and with Hybrid-PET elsewhere in the body. Additional malignant disease other than the head and neck tumor was found in 4 patients. CONCLUSION: Using Hybrid-PET for [F-18]FDG imaging reveals a loss of sensitivity and specificity of about 1-5% as compared to dedicated PET in head and neck tumors. [F-18]FDG PET with both, dedicated PET and Hybrid-PET is superior to CT in the diagnosis of primary or recurrent lesions as well as in the assessment of lymph node involvement.

[Spiral CT of the abdomen: weight-adjusted dose reduction]. / Spiral-CT des Abdomens: Gewichtsadaptierte Dosisreduktion.

AIM OF THE STUDY: The influence of weight-adjusted current application in spiral CT of the abdomen on noise was investigated in a clinical study. PATIENTS AND METHODS: In 77 routine abdominal CT investigations (120 kV, 8 mm, pitch 1.5) the patients were divided into three body-weight groups A (< 60 kg), B (60-80 kg), and C (> 80 kg). The tube current was randomized prospectively in low weight group A, either 125 mA or 150 mA, in middle and high weight groups B and C, 150, 175 or 200 mA, with a tube revolution time of one second. The noise was measured in liver, skeleton muscle, fat tissue, and bladder content for evaluation of image quality. RESULTS: The bodyweight groups differ significantly in noise, e.g., in the liver (150 mA): group A: 15.8 HU, group B: 18.9 HU, group C: 21.5 HU. The increase of tube current (150, 175, 200 mA) within a body weight group resulted in a minor decrease of noise (18.9 HU, 17.6 HU, 17.5 HU, respectively, in group B). There is a good correlation of noise with body weight, body mass index and body cross section, but not with body size. CONCLUSION: A body weight adjusted reduction of tube current is possible without an increase of noise.

Molecular evidence for different stages of tuberculosis in ancient bone samples from Hungary.

This paleomicrobiologic study was conducted on osseous tissue specimens from ancient Hungarian skeletal samples from the 7-8th and the 17th centuries AD with typical macromorphologic evidence of osseous tuberculosis (n = 3), morphologic alterations probably due to tuberculosis (n = 6), or with nontypical osseous changes of vertebral bodies suggestive of inflammatory reaction (n = 5). From these bone samples, DNA was extracted and amplified by polymerase chain reaction (PCR) by using various primer pairs recognizing DNA segments of different mycobacterial species. To confirm specificity of the analysis, the amplification products of several samples were subjected to restriction enzyme digestion and/or direct sequencing. Of the analyzed 14 cases, 8 were unambiguously positive for mycobacterial DNA of the Mycobacterium tuberculosis complex, as shown by the amplification of the IS6110 sequence. In 13 cases we found a PCR product with primers specific for the 65-kDa antigen gene, including 2 cases without genomic DNA. We conclude that the application of other mycobacterial DNA primers may reveal contamination of bones with atypical saprophytic mycobacteria. A positive result for typical mycobacteria was seen in 2 of 3 cases with typical morphologic signs of tuberculosis and amplifiable DNA, in 3 of 6 probable cases, but also in 3 of 6 cases with nontypical bone changes. This indicates that minor osseous reactions of the surface of vertebral bodies may be due-at least in several cases-to infections with bacteria of the M. tuberculosis complex. In these cases the disease may have proceeded rapidly, and the morphologic osseous changes may represent "early" stages of tuberculous infection of the vertebrae.

Detection of leprosy in ancient human skeletal remains by molecular identification of Mycobacterium leprae.

We isolated ancient DNA from skeletal remains obtained from a South German ossuary (approximately 1400-1800 AD) and from a 10th century Hungarian cemetery partially indicating macromorphologic evidence of leprosy. In samples taken of 2 skulls from Germany and of 1 hard palate from Hungary, Mycobacterium leprae-specific fragments of RLEP1 and RLEP3 were amplified using polymerase chain reaction (PCR), thereby confirming their specificity by sequencing. In another case, PCR with primers targeting IS6110 of Mycobacterium tuberculosis gave positive results only for a mandibular specimen. No signal for any mycobacterial DNA was observed in samples from 2 Hungarian foot bones. In ancient material, osseous involvement of M leprae may be detected and distinguished from other mycobacterial infections by specific PCR. In the small bones of leprous hands and feet, not enough M leprae DNA seems to be present for detection. This supports the view that rhinomaxillary leprous alterations result from direct bacterial involvement, while osseous mutilations of hands and feet result from a nervous involvement and/or secondary infections due to small lacerations of the overlying soft tissues.

Endoluminal repair of peripheral arterial aneurysms: 4-year experience with the cragg endopro system I.

PURPOSE: To assess the efficiency and long-term patency of the Cragg EndoPro System I in patients with peripheral arterial aneurysms. MATERIALS AND METHODS: In 10 patients, 13 stent-grafts were used to treat 15 arterial aneurysms. Aneurysms were located in the common iliac (n = 4), superficial femoral (n = 4), popliteal (n = 3), and subclavian arteries (n = 2), and in a femoropopliteal bypass-graft (n = 2). Follow-up ranged between 2 and 46 months (mean, 36 months). Examination included clinical status, color-coded duplex sonography, computed tomography angiography, and intra-arterial digital subtraction angiography (DSA). RESULTS: Technical success was achieved in all patients. Primary patency was four of four in iliac vessels and three of nine in non-iliac vessels; secondary patency in noniliac vessels was four of nine. Repairs included one local lysis, four percutaneous transluminal angioplasties, one surgical thrombectomy, and one bypass surgery. Stent wire disintegration was detected in one of four iliac stent-grafts and in seven of nine noniliac stent-grafts. In noniliac grafts, significant stenoses occurred in three of nine; occlusion occurred in five of nine. One complication at the iliac level was a vessel wall penetration at the proximal stent edge, with development of a new aneurysmal formation. No late endoleaks were found. CONCLUSION: Exclusion of peripheral arterial aneurysms with stent-grafts is feasible. Long-term results are excellent in iliac vessels. Mechanical weakness of the stent assembly and frequent re-stenoses or occlusions are significant drawbacks in noniliac vessels with low patency rates.

Anthropological and palaeopathological analysis of the human remains from three "Tombs of the Nobles" of the necropolis of Thebes-west, upper Egypt.

During several recent excavation campaigns at the necropolis of Sheikh-Abd-el-Gurna, Thebes-West, Upper Egypt, we investigated the human remains of three "Tombs of the Nobles" totalling at least 273 individuals. The investigation covered the human material (skeletons and mummy residues) from the tombs TT-84, TT-85 and TT-95. These tombs had been built in the New Kingdom (approx. 1500-1000 B.C.) and used until the Late period (up to 330 BC). All samples were analyzed macroscopically, isolated findings were further investigated by endoscopic and radiological techniques. The at least 273 individuals covered an age range from newborns to senile individuals with a main age of death between 20 and 40 years of age. The rate of infants and subadults was at 20.2% of all individuals and there was a slight male predominance comprising 54.5% of the adults. In this population a fairly high rate of pathological lesions was seen. Thus, dental conditions generally were poor with a high degree of dental abrasion, an also high rate of carious dental lesions (affecting between 13.8% and 27.7% of the yaws) and consequently a significant number of dental abscesses (mean 15.9%). Residues of trauma were observed in a considerable number of individuals ranging between 12.3% and 22.6% depending on the burial place (mean 15.8%). Inflammatory bone reactions (except the dental abscesses) were present to variable extent, in some locations ranging up to 6.8% of the cases (mean 5.1%). In addition, we noted several cases showing cribra orbitalia (mean 29.2%) and porotic hyperostosis (15.4% of cases), mild to severe osteopenia (7.5%) and in several cases subperiosteal new bone formation suggestive of chronic vitamin D-deficiency ("scurvy") (9.5%). The data support the notion of a significant impairment of living conditions in a high number of individuals. The rates of osteoarthrotic joint alterations were considerably variable depending on the burial places (between 1.9% and 18.5%) providing insight into the physical activities of subpopulations in different locations of the burial places. Similarly, the rate of spondylosis showed also variable extent ranging between 12% and 66.1% of vertebral bodies. In general, our analysis provides evidences that the living conditions in the ancient Egyptian population of one of the main necropoles of Thebes analyzed in this study were quite poor. This is somewhat in contrast to the usually assumed high standard of living of the socially higher population of the capital of ancient Egypt.

Malignant tumors in an ancient Egyptian population.

Since it is still an open debate whether malignant tumors are mainly influenced by environmental factors, the frequency of such malignant tumors in historic populations with different living conditions is of particular interest. In the present study, we investigated the occurrence of malignant tumors affecting bone tissue in a population of mumrnies and skeletons, which had been excavated from the large necropolis of Thebes-West, Upper Egypt. Our study material comprised a series of at least 415 individuals (thereof 325 adults) dating from approx. 1500-500 B.C. All individuals had been mummified, but were severely damaged and partially broken by grave robbers, so that often only parts of the mummies/skeletons were available for investigation. The available specimens were subjected to careful macroscopic examination, while isolated findings were radiologically analyzed. Using this approach, we identified at least 4 cases showing malignant tumors affecting the skeleton. In two cases, multiple mixed osteolytic-osteoblastic lesions suggested multiple metastases from carcinomas. Two further individuals presented with multiple osteolyses (vertebra, pelvis, skull) most suggestive of multiple myeloma. The observation of at least 4 cases of malignant tumors with osseous manifestation in a series of 325 adult individuals provides clear evidence that malignant tumors were not a rare event in the ancient Egyptian study population, particularly when the limitations of a study of tumors manifested only in osseous remnants are taken into consideration. A calculation of the age- and sex-adjusted tumor frequency in our material in comparison with a recent model for such a material by Waldron (1996) indicates that the rate of malignant tumors with bone affection in our series is higher than in an English population from 1901-1905, although lower than in a comparable present day population. This clearly indicates that important factors affecting malignant tumors were effective even in historic populations.

Successful exclusion of subclavian aneurysms with covered nitinol stents.

Two cases of percutaneous endoluminal exclusion of a subclavian aneurysm with a Dacron-coated nitinol stent are presented. One subclavian aneurysm followed trauma; the other was due to thoracic outlet stenosis which was caused by a cervical rib. In both patients the aneurysm was excluded successfully. The follow-up periods were 22 and 14 months, respectively. Stenoses at the stent graft occurred in both patients; one was treated by balloon angioplasty. In selected patients, endoluminal grafting could be an alternative to surgery; however, stent graft designs need to be improved and long-term follow-up is awaited.

The scapholunate interosseous ligament in MR arthrography of the wrist: correlation with non-enhanced MRI and wrist arthroscopy.

OBJECTIVE: To compare three-compartment MR wrist arthrography with non-enhanced MRI in correlation with wrist arthroscopy, and to evaluate the potential of MR arthrography for consistently visualizing all parts of the scapholunate interosseous ligament of the wrist (SLIL) and exactly diagnosing the site and extent of SLIL defects. DESIGN AND PATIENTS: In 41 patients with wrist pain (34 patients with wrist pain for more than 6 months) plain radiographs, stress views, non-enhanced MRI and three-compartment MR arthrography were done within 2 h of each other, using three-dimensional volume acquisition (0.6-1.0 mm effective slice thickness) with a gradient-recalled echo sequence and a 1.5-T magnet. The MR arthrography findings were compared with the findings from non-enhanced MRI and correlated with the arthroscopic findings in all patients. RESULTS: The dorsal, central and palmar segments of the SLIL could be delineated exactly by MR arthrography in 95% of the patients; with non-enhanced MRI only 28% of SLIL segments were seen consistently. Demonstration of SLIL defects was possible with high diagnostic confidence in 42% of SLIL segments by non-enhanced MRI and in 94% by MR arthrography. With wrist arthroscopy as the standard of reference, sensitivity and specificity values for SLIL perforations were 52%/34% for non-enhanced MRI and 90%/87% for MR arthrography. CONCLUSIONS: MR arthrography, using three-dimensional volume acquisition with thin slices (0.6-1.0 mm), combines the advantages of three-compartment arthrography and non-enhanced MRI. It shows the precise location and magnitude of ligamentous defects of all parts of the SLIL, correlates well with wrist arthroscopy and has potential implications for diagnosis and treatment planning.

[Instrumental diagnosis for therapeutic decision: intra-arterial DSA versus 3D CT-angiography in abdominal aortic aneurysms]. / Apparative Diagnostik zur Therapieentscheidung: Intraarterielle DSA versus 3D-CT-Angiographie bei abdominellen Aortenaneurysmen.

Compared to intraarterial DSA, 3D spiral CT-angiography could be an reliable alternative method for preoperative evaluation and planning of abdominal aortic aneurysms. 3D data reconstruction with new rendering techniques (especially "volume rendering") provides unique information about mural thrombus, calcified plaques, vessel kinking and renal/visceral arteries. However, the more invasive intraarterial DSA should be performed in patients with complex occlusive disease of the iliac arteries, renal or visceral artery stenoses, or pathological findings in peripheral duplex sonography or if intraluminal exclusion with endostent placement is planned.

[Combined interventions in transfemoral stent implantation in infra-renal abdominal aortic aneurysm]. / Kombinierte Eingriffe der transfemoralen Stentprothesenimplantation beim infrarenalen Bauchaortenaneurysma.

The transluminally placed endovascular graft (TPEG) is a novel method for the treatment of abdominal aortic aneurysms (AAA). Aortobiiliacal application requires three anchor sites and can often not be performed in cases of aneurysm, occlusion, or elongation of the iliac arteries. Here the aorto-uniiliacal stent implantation combined with crossover bypass provides an alternative procedure, and thus broadens the therapeutic endovascular spectrum.

Late thromboembolic complication from a Palmaz stent in the common iliac artery.

A 56-year-old smoker presented with rest pain in his left leg and hyperfibrinogenemia. He was found to have a high-grade stenosing thrombus in a Palmaz stent which had been placed 4 years ago across a stenosing ulcerating plaque in the left common iliac artery. Systemic thrombolysis was successful but the patient refused long-term anticoagulation. He presented 2 months later with recurrent stent thrombosis and an embolus to the tibioperoneal trunk. Systemic lysis was successfully performed for the stent reobstruction but the distal embolic occlusion responded neither to systemic nor to local thrombolysis. This case suggests that patients with vascular stents and hyperfibrinogenemia and/or nicotine abuse should be considered candidates for long-term anticoagulation.

[The percutaneous treatment of surgical and catheter-angiographic vascular complications]. / Perkutane Behandlung chirurgischer und katheterangiographischer Gefässkomplikationen.

PURPOSE: Technical innovations of angioplasty have introduced new therapeutic options in the treatment of symptomatic arteriosclerotic disease. Atherectomy devices, aspiration catheters and vascular endoprostheses can be used not only for angioplasty purpose but also for correction of iatrogenic dissections and thromboembolic complications. MATERIAL AND METHODS: 54 patients with vascular complications after surgical (n = 7) and percutaneous (n = 47) interventions were observed in a 5 years period. The complications included acute dissections in 34 cases, acute thrombosis in 4 cases, distal embolism after angioplasty in 14 cases, and two cases with arterial rupture after balloon dilatation. RESULTS: 34 patients with dissections and 18 patients with acute thrombosis were treated. Stent implantation for repair of vessel dissection was successful in 33 of 34 cases. Percutaneous catheter aspiration in combination with local thrombolysis was successful in 4 cases with local thrombosis. Distal emboli after angioplasty were successfully removed using aspiration catheters in 13 of 14 patients. Vessel rupture after angioplasty was closed with prolonged balloon dilatation in two patients avoiding emergency surgery. CONCLUSION: Using newly developed intravascular technologies such as atherectomy, stents, and catheter aspiration, many iatrogenic complications after vascular surgery or vascular interventions can be treated. These technologies should be available in every radiology department performing angioplasty.