Combined PET/MRI: from Status Quo to Status Go. Summary Report of the Fifth International Workshop on PET/MR Imaging; February 15-19, 2016; Tübingen, Germany.

This article provides a collaborative perspective of the discussions and conclusions from the fifth international workshop of combined positron emission tomorgraphy (PET)/magnetic resonance imaging (MRI) that was held in Tübingen, Germany, from February 15 to 19, 2016. Specifically, we summarise the second part of the workshop made up of invited presentations from active researchers in the field of PET/MRI and associated fields augmented by round table discussions and dialogue boards with specific topics. This year, this included practical advice as to possible approaches to moving PET/MRI into clinical routine, the use of PET/MRI in brain receptor imaging, in assessing cardiovascular diseases, cancer, infection, and inflammatory diseases. To address perceived challenges still remaining to innovatively integrate PET and MRI system technologies, a dedicated round table session brought together key representatives from industry and academia who were engaged with either the conceptualisation or early adoption of hybrid PET/MRI systems. Discussions during the workshop highlighted that emerging unique applications of PET/MRI such as the ability to provide multi-parametric quantitative and visual information which will enable not only overall disease detection but also disease characterisation would eventually be regarded as compelling arguments for the adoption of PET/MR. However, as indicated by previous workshops, evidence in favour of this observation is only growing slowly, mainly due to the ongoing inability to pool data cohorts from independent trials as well as different systems and sites. The participants emphasised that moving from status quo to status go entails the need to adopt standardised imaging procedures and the readiness to act together prospectively across multiple PET/MRI sites and vendors.

Chondroid tumors arising from the meninges--report of 2 cases and review of the literature.

Chondroid tumors are rare intracranial tumors usually arising from the base of the skull. We present 2 cases of intracranial cartilaginous tumors with unusual location. In case 1, a 19-year-old woman, a chondroma of the falx cerebri with extensive secondary ossification was diagnosed. In case 2, a 30-year-old woman, a low-grade chondrosarcoma was resected from the right frontal lobe. Both patients showed an uneventful clinical course without evidence of disease 4.5 and 6 years after total extirpation. Our cases show that chondromas and low-grade chondrosarcomas of the dura and meninges usually occur in young adults with a good prognosis after complete extirpation.

Detection of pulmonary nodules at spiral CT: comparison of maximum intensity projection sliding slabs and single-image reporting.

The aim of this study was to compare numbers of pulmonary nodules detected with maximum intensity projections using a slab thickness of 15 mm (MIP 15) and 30 mm (MIP 30) with single image (SI) presentation of chest CT scans. Two readers reviewed MIP 15, MIP 30, and SI presentations of 10-mm (n = 8) and 5-mm collimation (n = 10) helical CT scans and recorded size, location, and diagnostic confidence (definite, probable) of pulmonary nodules. Readers 1 and 2 recorded more nodules with MIP 15 than with SI: 10-mm collimation, 77/64 and 60/56; 5-mm collimation, 64/60 and 40/36; and more "definite" nodules (10-mm collimation: 68/57 and 51/42; 5-mm collimation: 43/36 and 34/30). MIP 15 also detected more nodules than MIP 30 at 10-mm collimation: 77/72 and 60/50; with no major differences at 5-mm collimation: 64/66 and 40/38; and more "definite" nodules (10-mm collimation: 68/58 and 51/36; 5-mm collimation: 43/39 and 34/29). There were only minor differences between SI and MIP 30. Reading time and image number per study were reduced with MIP presentations by a factor of 1.4-5.3. There were no significant differences in the number of nodules detected with SI, MIP 15, and MIP 30, but MIP presentation reduced reporting time and filming cost when compared with SI reporting. For detection of nodules MIP 15 was slightly superior to MIP 30.

Spiral CT of pulmonary nodules: interobserver variation in assessment of lesion size.

The aim of this study was to assess interobserver variability in size determination of pulmonary nodules at spiral CT. Twenty-three patients with known pulmonary nodules (diameter 2-40 mm, mean diameter 7 mm) underwent spiral chest CT (collimation 5 mm, pitch 1). Images were reconstructed at 3- and 5-mm intervals (RI). Hard copies were analyzed by two radiologists who recorded every nodule with regard to location, diagnostic confidence ("definite," "probable") and nodule size in increments of 1 mm with specific attention to correct classification into one of three size classes (< or = 5 mm, 6-10 mm, > 10 mm). Interobserver variability was determined with Pearson's correlation coefficient and kappa measure. Of a total of 286 nodules, 103 nodules were found accordingly by both readers at 3 mm RI, and 96 at 5 mm RI. There was a good correlation of measurements (in millimeters) between both readers (Pearson's correlation coefficient: 0.89-0.95). Interobserver variability in categories was good at both reconstruction intervals (kappa: 0.61 at 3 mm, 0.74 at 5 mm RI) and very good (0.81) at 5 mm RI when uncertain nodules were excluded. Spiral CT allows reproducible size determination of pulmonary nodules as shown by good interobserver agreement in exact size measurement and categorization into three size classes.

[Atypical hypertrophic cardiomyopathy with calcified, left ventricular apical thrombosis]. / Atypische hypertrophe Kardiomyopathie mit verkalktem, linksventrikulärem Spitzenthrombus.

A case of atypical hypertrophic cardiomyopathy (HCM) with a calcified apical thrombus is presented. A 42 year old asymptomatic patient was admitted for evaluation of an abnormal electrocardiogram (ECG) which was recorded when the patient suffered from a bronchitis. The ECG showed giant negative T-waves in leads II, III, aVF, V3 to V6 associated with high QRS voltages in the precordial leads. The chest X-ray and fluoroscopy demonstrated a calcification in projection to the apical region of the heart. Echocardiography and the left ventricular (LV) cineangiography showed hypertrophy of the apical LV myocardium and an obliteration of the apical LV cavity. Magnetic resonance imaging identified a calcified thrombus in the apical cavity of the LV in the setting of an atypical HCM.

Detection of pulmonary nodules with overlapping vs non-overlapping image reconstruction at spiral CT.

The aim of this study was to analyze whether overlapping image reconstruction increases numbers of pulmonary nodules detected at helical CT. Forty-eight helical CT scans (21 with a slice thickness of 10 mm; 27 with a slice thickness of 5 mm) of patients with known pulmonary nodules were reconstructed both with overlapping and non-overlapping image reconstruction. Two readers recorded number and size of pulmonary nodules as well as diagnostic confidence. With overlapping image reconstruction each reader diagnosed more pulmonary nodules (slice thickness 10 mm: +24.0 and +26.7%, both p < 0.01; slice thickness 5 mm: +9.5 and +11.9%, both not significant) and more "definite" nodules (slice thickness 10 mm: +20.3%, p < 0.05, and +30.8%, p < 0.005; slice thickness 5 mm: +18.0 and +17.0%, both p < 0.05). Nodules diagnosed with overlapping image reconstruction only were almost exclusively smaller than the slice thickness. The increase in number of nodules detected was not associated with a decrease in diagnostic confidence. Overlapping image reconstruction improves detection of pulmonary nodules smaller than the slice thickness at spiral CT.

Helical CT of pulmonary nodules in patients with extrathoracic malignancy: CT-surgical correlation.

OBJECTIVE: Our aim was to assess the sensitivity of helical CT for revealing pulmonary nodules. Thoracotomy with palpation of the deflated lung, resection, and histologic examination of palpable nodules was used as the gold standard. SUBJECTS AND METHODS: Thirteen patients underwent helical CT (slice thickness, 5 mm; reconstruction intervals, 3 mm and 5 mm; interpreted by two independent observers). Subsequently, patients underwent unilateral (n = 6) or bilateral (n = 7) surgical exploration, and CT-surgical correlation of 20 lungs was performed. RESULTS: Ninety nodules were resected (61 were smaller than 6 mm; 13 were 6-10 mm; 11 were larger than 10 mm; in five nodules, the size was not recorded at surgery). Sixty-nine nodules were located in the pulmonary parenchyma and 21 in the visceral pleura. Of the 90 lesions, 43 (48%) were found on histology to represent metastases. For lesions detected by at least one observer, the sensitivity of helical CT was 69% for intrapulmonary nodules smaller than 6 mm, 95% for intrapulmonary nodules larger than or equal to 6 mm, and 100% for histologically proven intrapulmonary metastases larger than or equal to 6 mm. For lesions smaller than or equal to 10 mm, sensitivity was better using a reconstruction interval of 3 mm rather than of 5 mm. CONCLUSION: In this study, the sensitivity of helical CT exceeded the sensitivity of conventional CT in previous reports. However, because of limitations in the detection of intrapulmonary nodules smaller than 6 mm and of pleural lesions, complete surgical exploration should remain the procedure of choice in patients undergoing pulmonary metastasectomy. Preoperative helical CT should be used to guide the surgeon to lesions that are difficult to palpate.

Metabolic characterization of AIDS dementia complex by spectroscopic imaging.

Prospective proton chemical shift imaging (CSI) of the brain was performed in 30 HIV- 1-seropositive patients and 11 healthy controls. Significant (P < 0.05) reductions in the N-acetyl-L-aspartate (NAA)/total creatine (Cr), and NAA/total choline (Cho) ratios and significant increases in Cho/Cr occurred in patients with 1) AIDS-defining diagnoses; 2) <200 CD4 lymphocyte counts/microl; 3) neurological evidence for an AIDS dementia complex (ADC); 4) magnetic resonance imaging (MRI) signs of cerebral atrophy. The basal ganglia and the insula were affected to approximately the same extent and without indications of spatial variations within these areas. Reduced NAA seems to indicate progressive neuronal injury or loss due to productive HIV infection in the brain and its clinical picture ADC. Spectroscopic abnormalities were, however, also observed in neurologically normal HIV patients or those with normal MRI results. Proton CSI may therefore serve as an early quantitative marker of central nervous system involvement in AIDS.

Intracranial vascular stenosis and occlusion: comparison of 3D time-of-flight and 3D phase-contrast MR angiography.

We compared the value of 3D time-of-flight (TOF) and phase-contrast (PC) MR angiography (MRA) for detection and grading of intracranial vascular steno-occlusive disease. Unenhanced 3D-TOF MRA and 3D-PC MRA (30-60 cm/s velocity encoding) were performed at the level of the circle of Willis in 18 patients, mean age 56 +/- 10 years. Postprocessed images using a maximum-intensity projection reconstruction with multiple targetted projections were analysed. A total of 126 vessels was assessed by PC MRA and 143 by TOF MRA, with digital subtraction angiography (DSA) in 15 patients and/or transcranial Doppler sonography (TCD) in 18 as a standard. Two blinded readers reviewed the MRA, DSA and TCD examinations retrospectively. On DSA and/or TCD the two observers found 32 and 28 steno-occlusive lesions. 3D-TOF MRA was more sensitive than 3D-PC MRA (87% and 86% vs. 65% and 60%) and had a higher negative predictive value (96% vs. 89%). Correct grading of stenoses was achieved in 78 % by 3D-TOF and 65% by 3D-PC MRA.

Contrast-enhanced magnetic resonance angiography of peripheral vessels. Different contrast agent applications and sequence strategies: a review.

In this article the relation between contrast medium (CM) application and sequence parameters will be discussed with respect to clinical use of the contrast-enhanced magnetic resonance angiography (CE-MRA) in the peripheral vessel region. The adjustment of the sequence parameters, the CM application timing and the bolus geometry is necessary for an effective use of CE-MRA. Investigation protocols for several vascular regions differ mainly corresponding to varying fields of view and slab thickness. Restrictions of increasing the measurement time are expected in peripherally localized vessels if fast arteriovenous transit time occurs. The vessel contrast depends from (1) optimal CM bolus timing and (2) bolus geometry defined by the parameters of the intravenous bolus injection (flow rate, dose and NaCl flush volume). Our study results have shown that the bolus remains compact but also shorter if a higher flow rate is being applied at equal dose. The enlargement of the NaCl flush volume has evidently caused an increased intraarterial CM concentration and a slightly bolus lengthening. The exact timing regimen requires an automated mechanical CM injection pump. In most countries, a total dose of 0.3 mmol/kg Gd is allowed for application during one investigation. Therefore, obtaining an angiogram of the entire iliac and leg region this total dose must be separated. 0.1 mmol/kg for each of the three measurements can be recommended. Otherwise, using this lower CM dose results in less spatial resolution. At least a dosage of 0.2 mmol/kg Gd is necessary to achieve a higher spatial resolution. The calculation of CM dosage should be also related to the dedicated vessel region of interest than to the body weight only.

Breath-hold gadolinium-enhanced MR angiography of the major vessels at 1.0 T: dose-response findings and angiographic correlation.

PURPOSE: To find the appropriate contrast agent dose for gadolinium-enhanced magnetic resonance (MR) angiography by using individual measurement of contrast agent transit times in a randomized study. MATERIALS AND METHODS: A total of 34 patients with disease of the aorta or its major branches or both were randomly assigned to receive a dose of 0.1, 0.2, or 0.3 mmol of gadopentetate dimeglumine per kilogram of body weight. Initially, contrast agent transit times were measured with use of a turbo fast-low-angle-shot sequence. Subsequently, a three-dimensional fast imaging with steady-state precession sequence (7.3-msec repetition time, 2.8-msec echo time) was used for breath-hold MR angiography. Gadopentetate dimeglumine was injected with an MR-compatible power injector. Efficacy was evaluated by measurement of vessel enhancement and by clinical correlation of MR angiograms with x-ray angiograms. RESULTS: Evaluation of contrast agent transit time was possible in all patients with the test doses, which provided contrast-enhanced MR angiograms of constant quality. Neither vessel enhancement nor diagnostic information was significantly different across the these study groups. CONCLUSION: The clinical gadolinium dose of 0.1 mmol/kg is sufficient for diagnostic assessment of the aorta and its major branches at contrast-enhanced MR angiography. High-dose studies appear not to be required for these large vessels.

[Combined use of ECK-triggered 2D-phase contrast MR angiography and 2D-time-of-flight MR angiography for planning and follow up before and after vascular intervention of pelvic and leg arteries]. / Kombinierter Einsatz der EKG-getriggerten 2D-Phasenkontrast-MR-Angiographie und der 2D-Time-of-Flight-MR-Angiographie zur Planung und Verlaufskontrolle vor und nach Gefässinterventionen der Becken- und Beinarterien.

PURPOSE: To develop a strategy for the complete work-up of vessel lumen and vessel wall for planning and follow-up of radiological interventions of lower extremity arteries. METHODS: A total of 36 patients (21 pre-, 8 post- and 7 pre- and postinterventional) were studied. MRA studies were performed using an ECG-triggered phase contrast technique for the demonstration of intraluminal flow and an axial high resolution time-of-flight technique to assess the vascular wall. All MRA studies were analysed by intraindividual DSA comparison for the assessment of flow and wall structures. RESULTS: Combined MRA techniques provided a good correlation with DSA for the assessment of vascular flow. The kappa test revealed a value of greater than 0.61 for most on the vessel segments proving a good correlation of both methods. Orthogonal high-resolution TOF-MRA provided additional information for the assessment postinterventional wall haematomas and hard plaques. CONCLUSION: Combination of PCA to study flow and axial TOF to study wall pathology improves the usefulness of peripheral MRA.

SPIO-enhanced 2D-TOF MR angiography of the portal venous system: results of an intraindividual comparison.

The purpose of this study was to investigate whether MR angiography (MRA) of the portal venous system may be improved by means of superparamagnetic iron oxides (SPIOs) during accumulation phase imaging and to study the underlying contrast mechanisms. MRA of the portal venous system was performed on 48 patients before and after intravenous injection of a new SPIO (Resovist, Schering AG, Berlin, Germany). Resovist, as a predominantly liver parenchymal darkening agent on T2-weighted MR images with uptake into the reticuloendothelial cell system, was administered intravenously by bolus injection of 8 to 12 micromol Fe/kg body weight. Patients were scanned with breath-hold coronal and axial two-dimensional (2D) time of flight (TOF) MRA (TR = 31.0 msec, TE = 9.8 msec, flip angle (FA) = 50 degrees, and 6.9-second acquisition time per section) sequences. Signal intensity values of liver parenchyma, the portal venous system, and background were obtained for quantitative analysis. The clinical relevance of additional plain and contrast-enhanced MRA studies for surgical planning was assessed by independent reading of three readers. Liver signal-to-noise ratio (SNR) significantly decreased following iv injection of Resovist; however, SNR values of the portal veins or hepatic veins did not change significantly. Visibility of the portal venous system improved significantly (tertiary branches visible: pre in 15.2% versus post in 87.0% of patients). Resovist-enhanced 2D-TOF MRA may improve planning of liver resections by better demonstrating the relationship of central liver lesions and vessels on source images. The decrease in liver SNR at a constant vessel SNR after iv injection of Resovist improves MRA of the liver. SPIO-enhanced 2D-TOF MRA scans are superior to plain 2D-TOF MRA studies and may be added for the workup of preoperative patients.

[Phase-contrast MR angiography of the lower extremity. Comparison of methods and clinical application]. / Phasenkontrast-MR-Angiographie der unteren Extremität. Methodenvergleich und klinische Anwendung.

PURPOSE: To investigate whether phase-contrast MRA is a clinically suited approach to examine arteries of the pelvis and lower extremities. METHODS: The study was divided into two parts, a volunteer study and patient study. Three MRA techniques-2D TOF with venous saturation, 3D magnitude contrast and 2D phase contrast with ECG triggering-were intraindividually compared in 15 volunteers and evaluated by three blinded readers. Subsequently, a total of 230 vessel segments of 45 MRA studies using ECG-triggered phase contrast were compared with intraarterial DSA. All vessel segments were scored by three blinded readers using a five-point scale with DSA serving as the gold standard. RESULTS: ECG-triggered phase contrast provided better image quality than the other MRA techniques as assessed by the Friedman test. Clinical studies demonstrated a significant correlation of DSA and MRA as assessed by the Spearman correlation and kappa statistics for individual readers. CONCLUSION: MRA of the pelvis and lower extremities may be performed with 2D ECG-triggered phase-contrast MRA within a reasonable time frame (< 30 min). MRA slabs provide orientation similar to that with DSA projections and good to very good correlation of vessel pathology as shown by kappa statistics.

[The color Doppler-guided compression therapy of pseudoaneurysms. The authors' own experiences and a review of the literature]. / Farb-Doppler-gesteuerte Kompressionstherapie von Pseudoaneurysmen. Eigene Erfahrungen und Literaturübersicht.

PURPOSE: The common use of interventional angiographic techniques and the sensitive detection of this vascular complication by ultrasound are major factors contributing to the increasing incidence of femoral artery pseudoaneurysms. ultrasound-guided compression repair of femoral artery pseudoaneurysms was prospectively evaluated. MATERIAL AND METHODS: 11 femoral artery pseudoaneurysms were detected in 10 patients who ranged from 45 to 79 years of age. In one patient two ipsilateral pseudoaneurysms occurred. All patients were considered to be candidates for ultrasound-guided compression repair. RESULTS: Successful compression repair was achieved in 9 of 11 pseudoaneurysms (82%) with a mean diameter of 2.2 +/- 1.0 cm. In two recurrent lesions (22%) definitive thrombosis required a second treatment. Compression was maintained between 10 and 40 minutes (mean 22 +/- 11 minutes). No complications have been observed. CONCLUSIONS: Ultrasound-guided compression repair provides an efficient, noninvasive and safe treatment of femoral artery pseudoaneurysms. More than 80% of pseudoaneurysms can be occluded successfully. In recurrent lesions a second attempt is valuable.

[Phenomenology of pulmonary HRCT. Definitions, differential diagnosis and clinical relevance]. / Phänomenologie der pulmonalen HRCT. Definitionen, Differentialdiagnose und klinische Relevanz.

High-resolution computed tomography (HRCT) has proved to be the imaging technique of choice for the lung in numerous studies, allowing precise depiction of normal pulmonary anatomy-including the lobular architecture-as well as relevant pathologic changes. Its sensitivity, specificity and accuracy in this respect are markedly superior, not only to chest radiography, but also to conventional CT. Guidelines for standardized assessment and interpretation of HRCT findings have not been established in the German literature. The purpose of this paper was to develop a systematic classification of pulmonary HRCT findings based on the appearance of morphologic abnormalities (descriptive classification) and their relationship to anatomic structures of pulmonary parenchyma (anatomic classification). Reticular, nodular, and non-reticular/non-nodular densities, as well as lucencies, can be differentiated. Abnormalities of the pleural space are discussed separately. Following the presentation of typical CT findings, morphologic correlation and differential diagnosis are discussed. In addition, we point out indications and specific features of the clinical value of the technique.

[The value of 3-phase spiral CT and magnetic resonance tomography in preoperative diagnosis of pancreatic carcinoma]. / Die Wertigkeit der 3-Phasen-Spiral-CT und der Magnetresonanztomographie in der präoperativen Diagnostik des Pankreaskarzinoms.

UNLABELLED: The purpose of this study was to assess the role of spiral computed tomography (SCT) and magnetic resonance imaging (MRI) in the preoperative work-up of patients with pancreatic carcinoma, regarding local resectability and vascular involvement. METHODS AND MATERIALS: A total of 28 patients (19 men and 9 women; mean age 58 years) with known or highly suspected carcinoma of the pancreas were included in this study. All patients prospectively underwent MRI ( +/- gadolinium-DTPA ) and SCT (3-phase examination) as preoperative diagnostic imaging studies, and laparotomy was carried out within 7 days, irrespective of the MRI or SCT findings. SCT and MR studies were reviewed independently by two radiologists, without knowing the results of the surgical exploration. Standardized image analysis was correlated with findings at laparatomy. RESULTS: Laparotomy identified 10 patients to be suitable for surgical resection and 18 pancreatic carcinomas to be unresectable. In 17 of 18 non-resectable carcinomas MRI and SCT were able to obtain correct information about unresectability (sensitivity 94%), in 7 (MRI), resp. 8 (SCT) carcinomas were correctly considered to be resectable (sensitivity 70% of MRI and 80% for SCT). The presence of vascular involvement was depicted by SCT with a sensitivity of 82-100% and 62-100% by MRI. The specificity varied between 85-100% for SCT and 77-100% for MRI. CONCLUSION: Both MRI and SCT are good techniques for the preoperative work-up of pancreatic carcinomas in order to obtain a correct assessment of local resectability.

[Pulmonary varicose veins. Case report and review of the literature]. / Pulmonalvenenvarikose. Fallbeschreibung und Literaturübersicht.

Pulmonary varicosis is a rare, presumably congenital localized dilatation of a pulmonary vein which is often associated with cardiac disease. We describe a case featuring enlargement of a pulmonary varix after mitral valve replacement, caused by mitral regurgitation, and discuss diagnostic possibilities, differential diagnosis and various development of this vascular malformation. A detailed review of the literature is given.