Selective loss of vergence control secondary to bilateral paramedian thalamic infarction.

The supranuclear pathways for vergence eye movements are poorly understood. The authors report a 57-year-old patient who presented with selective loss of vergence control and dissociation of light and near reaction. MRI showed a symmetric paramedian thalamic infarction without midbrain lesion. The findings suggest that this syndrome is due to an interruption of supranuclear fibers to midbrain vergence neurons.

D-dimer and TAT measurement in patients with deep venous thrombosis: utility in diagnosis and judgement of anticoagulant treatment effectiveness.

The plasma levels of thrombin-antithrombin III-complexes (TAT) and the fibrin split product D-Dimer were measured in 39 patients with phlebographically proven acute DVT: 34 patients had proximal DVT, 5 had calf DVT. The sensitivity of D-Dimer and TAT measurements in the diagnosis of proximal DVT was found to be dependent on the duration of symptoms: 0 to 7 days (n = 27): elevated D-Dimer levels (greater than 120 ng/ml) = 1, D-Dimer Latex test positive (greater than 500 ng/ml) = 1, elevated TAT levels (greater than 6 ng/ml) = 0.88. Eight to 14 days (n = 7): elevated D-Dimer levels = 1, D-Dimer Latex test positive = 0.33, elevated TAT levels = 0.66; specificity: elevated D-Dimer: 0.48, D-Dimer Latex test: 1, elevated TAT: 0.76. Calf DVT patients (n = 5) had elevated D-Dimer levels, negative Latex tests and 3 of them had normal TAT values. Hemostatic and fibrinolytic parameters were also determined in 13 patients during heparin treatment of proximal DVT. Elevated D-Dimer and TAT levels rapidly decreased after initiation of anticoagulant therapy. In 2 of 13 patients a marked increase in D-Dimer and TAT levels was observed in periods of ineffective heparinization, documented by normal or only slightly prolonged thrombin clotting times. We conclude from our results that 1) D-Dimer EIA measurement, in contrast to TAT measurement, shows a very high sensitivity in the diagnosis of DVT, 2) due to low specificity this test can only be used to exclude thrombosis in patients with suspected DVT, and 3) the determination of the plasma levels of D-Dimer and TAT may be useful for judging the effect of anticoagulant treatment on thrombotic processes.

Diagnosis of gallbladder perforation in acute acalculous cholecystitis in critically ill patients.

In the presence of ascites ultrasound is not appropriate to distinguish between gallbladder perforation and acute acalculous cholecystitis. However, the correct and early diagnosis of gallbladder perforation is important for the treatment and prognosis. We report 4 critically ill patients with ascites. All patients had evidence of gallbladder perforation by ultrasound and underwent cholecystectomy: 2 patients had gallbladder perforation, but 2 had acalculous cholecystitis without perforation. Markedly elevated serum alkaline phosphatase was the only discriminating finding indicating gallbladder perforation.

Radiographic detection of intrabronchial malpositions of nasogastric tubes and subsequent complications in intensive care unit patients.

OBJECTIVE: The aim of our study was to illustrate the radiographic spectrum of the intrabronchial malposition of nasogastric tubes and subsequent complications, and to discuss the role of radiography in the detection of such malpositions. DESIGN: Retrospective clinical investigation. SETTING: Tertiary care university teaching hospital. PATIENTS AND METHODS: We reviewed chest radiographs of 14 intensive care patients with nasogastric tubes malpositioned in the tracheobronchial tree. The site and anatomic location of the malposition were recorded. Complications due to tube malpositioning were monitored on follow-up radiographs and on computed tomographic examinations, which were available in 4 patients. RESULTS: Nine of 14 nasogastric tubes were inserted in the right and 5 in the left tracheobronchial tree. Tube tips were malpositioned in the lower lobe bronchi (50%), the intermediate bronchus (36%), and the main bronchi (14%). There was perforation of the bronchial system with subsequent pneumothorax in 4 patients. In 4 other patients, pneumonia developed at the former site of the malpositioned tube tip. Radiographic detection of nasogastric tube malpositioning was prompt in 9 patients and delayed in 5 patients. CONCLUSIONS: Whereas clinical signs of nasogastric tube malpositioning in intensive care patients may be absent or misleading, chest radiography can accurately detect nasogastric tube malpositions in the tracheobronchial tree, may prevent complications, and avoid the use of further costly or invasive diagnostic techniques.

Measurement of time-to-peak parameter by use of a new standardization method in patients with stenotic or occlusive disease of the carotid artery.

BACKGROUND AND PURPOSE: A quantitative, easily obtained measure of cerebral hemodynamics would be valuable in planning surgical or interventional therapy for patients with stenotic or occlusive disease of the carotid artery. We evaluated the recently introduced standardized time-to-peak variable (stdTTP), obtained with dynamic susceptibility contrast-enhanced MR (DSC-MR) imaging, in different states of stenotic/occlusive carotid artery disease. METHODS: We examined 24 patients with unilateral, high-grade stenosis (85%-95%) of one internal carotid artery (ICA) and 10 patients with stenosis (85%-95%) of one ICA and occlusion of the contralateral ICA. Mean stdTTP was evaluated in the central vascular territories of the anterior, middle, and posterior cerebral arteries and the anterior and posterior border zones and compared with the mean stdTTP values from 36 cerebral hemispheres without hemodynamic impairment. RESULTS: Patients showed no significant prolongation of stdTTP in the central vascular territories compared with the reference group, whereas significant prolongations of stdTTP were measured in the anterior and posterior border zones in patients with ICA disease (ANOVA, P <.05) and were most prominent in higher grades of carotid disease. Hemispheres with hemodynamic impairment always showed a stdTTP > 3.5 s in the border zones. CONCLUSION: The StdTTP quantitatively describes the hemodynamic impairment in cerebral hemispheres supplied by a stenosed or occluded ICA. An stdTTP value of > 3.5 s, as has been postulated, seems to point out hemodynamic impairment.

Spinal cord lesions in patients with multiple sclerosis: comparison of MR pulse sequences.

PURPOSE: To compare T2-weighted conventional spin-echo (CSE), fast spin-echo (FSE), shorttau inversion recovery (STIR) FSE, and fluid-attenuated inversion recovery (FLAIR) FSE sequences in the assessment of cervical multiple sclerosis plaques. METHODS: Twenty patients with clinically confirmed multiple sclerosis and signs of cervical cord involvement were examined on a 1.5-T MR system. Sagittal images of T2-weighted and proton density-weighted CSE sequences, T2-weighted FSE sequences with two different sets of sequence parameters, STIR-FSE sequences, and FLAIR-FSE sequences were compared by two independent observers. In addition, contrast-to-noise measurements were obtained. RESULTS: Spinal multiple sclerosis plaques were seen best on STIR-FSE images, which yielded the highest lesion contrast. Among the T2-weighted sequences, the FSE technique provided better image quality than did the CSE technique, but lesion visibility was improved only with a repetition time/echo time of 2500/90; parameters of 3000/150 provided poor lesion contrast but the best myelographic effect and overall image quality. CSE images were degraded by prominent image noise; FLAIR-FSE images showed poor lesion contrast and strong cerebrospinal fluid pulsation artifacts. CONCLUSIONS: The STIR-FSE sequence is the best choice for assessment of spinal multiple sclerosis plaques. For T2-weighted FSE sequences, shorter echo times are advantageous for spinal cord imaging, long echo times are superior for extramedullary and extradural disease. FLAIR-FSE sequences do not contribute much to spinal imaging for multiple sclerosis detection.

A standardized method of generating time-to-peak perfusion maps in dynamic-susceptibility contrast-enhanced MR imaging.

BACKGROUND AND PURPOSE: Perfusion MR imaging, performed as dynamic-susceptibility contrast-enhanced MR imaging, is sensitive to hemodynamic risks for patients with cerebrovascular disease. We sought to define a quantitative parameter for perfusion MR imaging, which shows brain areas at hemodynamic risk and enables direct comparison of different perfusion MR imaging examinations. METHODS: A new standardization procedure for the time-to-peak (TTP) parameter, standardized time to peak (stdTTP), was introduced. The stdTTP automatically calculates a time offset correlated to the earliest enhancing voxels in a section and rescales all TTP values accordingly. Because of a close relation between this offset and stdTTP of early enhancing voxels in central vascular territories (CVTs), stdTTP provides an estimate of the bolus run time between CVTs and related border zones (BZs). The stdTTP in CVTs and BZs was measured in 11 patients without hemodynamic impairment by using high temporal resolution dynamic-susceptibility contrast-enhanced perfusion MR imaging. RESULTS: An excellent comparability of different dynamic susceptibility contrast-enhanced MR imaging studies was found. The stdTTP in CVTs was 0.4 +/- 0.5 s (minimum, 0 s; maximum, 1.3 s) for the anterior, 0.5 +/- 0.3 s (minimum, 0 s; maximum, 1.0 s) for the middle, and 1.4 +/- 0.5 s (minimum, 0.4 s; maximum, 2.4 s) for the posterior cerebral artery. In the anterior BZ, stdTTP was 2.3 +/- 0.4 s (minimum, 1.6 s; maximum, 3.2 s), and in the posterior BZ, stdTTP was 2.8 +/- 0.4 s (minimum, 2.0 s; maximum, 3.4 s). CONCLUSION: The results suggest a limit for stdTTP of approximately 3.5 s in the anterior and posterior BZs. The stdTTP could serve as a quantitative measure for the hemodynamic risk assessment of patients with cerebrovascular disease. Because stdTTP can be directly derived from the measured curves, the hemodynamic situation of a patient can be judged with a minimum of computational effort.

Double inversion recovery imaging of the brain: initial experience and comparison with fluid attenuated inversion recovery imaging.

The purpose of this study was to evaluate the diagnostic efficacy of the double inversion recovery fast spin echo (DIR-FSE) sequence for brain imaging compared to the fluid-attenuated inversion recovery (FLAIR) sequence. DIR-FSE and FLAIR-FSE sequences were obtained and compared side by side. Image assessment criteria included lesion conspicuity, contrast between different types of normal tissue, image quality, and artifacts. In addition, contrast ratios and contrast-to-noise ratios were determined. Scan time of DIR-FSE was 33% longer than scan time of FLAIR-FSE. Overall lesion conspicuity was equal on DIR-FSE and FLAIR-FSE; however, DIR-FSE showed particular advantages for infratentorial lesions and lesions with only poor contrast on T2-weighted images, whereas FLAIR was slightly superior for small superficial cerebral abnormalities. Gray-white differentiation was better with DIR-FSE. Cerebrospinal fluid suppression was equal on both sequences; cerebrospinal fluid pulsation artifacts were more pronounced on DIR-FSE but did not cause diagnostic difficulties on these images. We conclude that DIR-FSE might be obtained if infratentorial lesions and abnormalities with only slightly prolonged T2 relaxation times are suspected. Otherwise, FLAIR-FSE seems preferable.

Comparison of Duplex sonography and color Doppler imaging in renal allograft evaluation: a prospective study.

A prospective study compared the diagnostic capability of quantitative Duplex sonography (DS) and color Doppler imaging (CDI) in 49 consecutive patients with 50 renal allografts. Sixty five DS examinations and 65 CDI examinations were performed by two independent investigators on two different machines on the same day. The resistive index (RI) was calculated and the color flow of renal arteries was observed up to the arcuate arteries. There was good correlation of RI values obtained by DS and CDI at all vascular sites. Thirty one allografts were functioning stably and 19 were in a state of dysfunction, defined by histology (n = 17). Forty allografts presented with a RI less than 0.9 and normal color flow. All five allografts with a pathologic RI greater than or equal to 0.9 showed abnormal color flow (missing flow in arcuate and/or interlobar arteries). Five allografts had a RI less than 0.9 but abnormal color flow, possibly due to atrial fibrillation, hypertension, heart failure or a combination of these. A normal color flow pattern excludes severe vascular compromise to the allograft. In addition, CDI revealed three biopsy-related vascular lesions; two of them had been missed by DS.

Contrast MRI in multiple endocrine neoplasia type 1 (MEN) associated with renal cell carcinoma.

The radiologic work-up of a patient with multiple endocrine neoplasia type 1 (MEN 1) syndrome and multiple endocrine nodules, with coincidental renal cell carcinoma, is described. Parathyroid adenoma was differentiated from multiple thyroid nodules by gadolinium-enhanced MRI. Adrenal enlargement due to a nonfunctioning adenoma and a renal cell carcinoma next to a simple renal cortical cyst were identified by typical signal intensities on T1- (pre- and post-Gd-DPTA) and T2-weighted images. Insulinoma was visualized only retrospectively.

[Breast ductal carcinoma in situ. The clinical image in the mammogram]. / Das duktale Mammakarzinom in situ. Erscheinungsbild im Mammogramm.

Thirty-one consecutive cases of ductal carcinoma in situ (DCIS) were retrospectively analysed to determine the spectrum of mammographic appearances. 68 per cent of the lesions appeared as microcalcifications, 52% as structural or irregular, poorly defined soft-tissue abnormalities, respectively. A mass lesion was noted in 23% of cases. 4 patients presenting with DCIS had negative mammograms and were diagnosed by means of additional examination techniques such as galactography, sonography, and cytologic evaluation in case of bloody nipple discharge. The authors conclude that there is a wide spectrum of mammographic imaging of DCIS.

[Vascular kidney transplant rejection--is a duplex sonographic diagnosis possible?]. / Vaskuläre Nierentransplantatabstossung--Ist eine duplexsonographische Diagnose möglich?

The diagnostic value of quantitative Duplex Doppler sonography (DS) in renal allograft evaluation is being viewed increasingly critically. We undertook a retrospective analysis of DS in 51 consecutive patients to assess the capability of DS in the diagnosis of vascular rejection. At the time of renal allograft biopsy, a mean resistive index (RI) was calculated from Doppler measurements within main, segmental, interlobar and arcuate arteries and correlated with histological diagnosis. Our results indicate a low specificity (36% for RI greater than 0.7), low sensitivity (35% for RI greater than 0.9) as well as a low positive predictive value (54% for RI greater than 0.7) for the diagnosis of vascular rejection. Therefore, elevation of the RI is an unspecific finding in different causes of allograft dysfunction. Thus, renal biopsy to establish specific histologic diagnosis of allograft dysfunction remains mandatory.

[Ultrasound follow-up of palpable solid, probably benign breast lesions (BI-RADS category III)]. / Sonographische Verlaufskontrollen bei palpablen soliden, wahrscheinlich gutartigen Brustläsionen (BI-RADS Kategorie III).

PURPOSE: To determine whether palpable non-calcified solid breast masses with benign morphology on ultrasound can be classified as probably benign and whether these lesions fulfill the criteria required for BI-RADS (TM) category III. MATERIALS AND METHODS: This analysis includes 78 patients with 80 palpable non-calcified solid masses that were classified as probably benign at initial sonography. Of 78 patients, 66 had periodic imaging surveillance (2 - 8 years, mean 4.6 years). The remaining 12 patients had a biopsy after initial imaging. RESULTS: In the 64 patients under surveillance, palpable lesions remained stable at follow-up. In 2 patients lesions increased in size during follow-up and no malignancy was diagnosed at subsequent open biopsy. In 19 of the 66 patients, 29 additional nonpalpable lesions of similar morphology were detected on ultrasound. No malignancy was diagnosed in the 12 patients, who had a biopsy after initial imaging. CONCLUSION: Our data suggest that palpable non-calcified solid breast masses with benign morphology on ultrasound can be classified as probably benign (BI-RADS (TM) category III). Biopsy can be averted when lesions remain stable at follow-up.

[Hepatic and splenic abscesses in immunosuppressed patients]. / Hepatale und lienale Abszesse bei immunsupprimierten Patienten.

Morphologic characteristics of hepatosplenic abscesses using ultrasound and CT examinations in 13 immunosuppressed patients are presented. Additionally, the results of diagnostic ultrasound and CT guided biopsy procedures (n = 13) are reported. On sonograms, bacterial abscesses were exclusively hypoechoic lesions whereas patients with mycotic abscesses showed additionally target lesions and lesions presenting a "wheels-within-wheels" appearance. Thus, with some limitations, us might help to differentiate between fungal and bacterial abscesses. On CT, all patients presented uniformly with hypodense lesions. Follow-up ultrasound studies showed these abscesses over periods as long as 24 months; biopsy proved some of these as fibrotic lesions without vital bacteria or fungi.

[Malignant and benign diseases of the breast in 41 male patients: mammography, sonography and pathohistological correlations]. / Maligne und benigne Erkrankungen der Brust bei 41 männlichen Patienten: Mammographie und Sonographie mit histopathologischer Korrelation.

AIM: The goal of our study was to evaluate findings in mammography and sonography in male patients with pathohistologically proven diseases of the breast. MATERIAL AND METHODS: Mammographies and sonographies, which were obtained in 41 male patients in a 6-year period, were retrospectively evaluated in accordance with the BI-RADS(R) classification. RESULTS: Histologically 13 carcinomas, 21 gynecomastias, 3 pseudogynecomastias, 2 epithelial inclusion cysts and 2 other benign lesions were diagnosed. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of mammography in differentiation of benign versus malignant disease were 92 %, 89 %, 80 %, 96 % and 90 %, respectively. Additional sonography did not change these results. However, sonography increased diagnostic confidence in 18.2 % (2/11) of suspicious lesions. CONCLUSION: In our study the invasive ductal carcinoma of male patients was a predominantly lobulated, ill-defined lesion in mammography and sonography. The differentiation of carcinoma to pseudogynecomastia and diffuse or dendritic gynecomastia was securely feasible. However, we could not reliably distinguish between carcinoma and some benign mass lesions. In cases of mammographically diagnosed masses or unclear mammography, additional sonography should be performed to increase the diagnostic confidence.

[The long-term changes after the implantation of silicone breast prostheses]. / Langzeitveränderungen nach Implantation von Mammasilikonprothesen.

In a prospective study 60 patients with unilateral or bilateral mammary implants underwent mammography and sonography. Location, form and structure of the implants were evaluated. Additionally capsular fibrosis and its influence on the imaging quality of parenchyma was scored. We found increasing implant deformities and increasing density of the implants with increasing postoperative interval. There was poor statistically significant correlation between the thickness of the periprosthetic capsular and the postoperative interval in prepectoral implants (r = 0.555, p < 0.01); in case of subpectoral implants there was no such correlation. In 88% of the cases imaging quality was scored as adequate by two independent observers, with additional views in all cases. We conclude that sufficient imaging quality for the assessment of parenchyma and of potential implants complications may be obtained by the combination of mammography and sonography.

[Extensive intraductal components of invasive ductal breast carcinoma--value of mammography]. / Die extensiv intraduktale Komponente von invasiven duktalen Mammakarzinomen--Stellenwert der Mammographie.

The presence of an extensive intraductal component (EIC) in patients with infiltrating ductal carcinoma is a major factor for predicting local recurrence after breast-conserving surgery and radiotherapy. A retrospective study including 67 consecutive cases of stage I and II infiltrating ductal carcinomas of the breast was conducted to determine the predictive values of mammographic features associated with the presence or absence of EIC. 43% of the lesions contained a pathologically verified EIC. 63% (25/40) of lesions showing mammographic evidence of calcifications with or without a mass were associated with an EIC. In contrast, only 17% (4/24) of carcinomas without calcifications demonstrated an EIC. This difference was statistically significant (p < 0.001). Lesions with calcifications greater than 3 cm in extent were significantly (p < 0.01) more likely to have an EIC (8/9; 89%) than those with calcifications less than 3 cm in extent (17/31; 55%). Furthermore, no patient with a palpable mass who had normal findings on mammograms was diagnosed to have an EIC.

Pyrofluid inhalation in "fire-eaters": sequential findings on CT.

We report the sequential computed tomography (CT) findings in two fire-eaters after accidental inhalation of pyrofluid. The initial chest radiographic findings were ambiguous and the interpretation of the radiographs was biased by clinical history unrelated to fire eating. On CT, pneumatoceles were the major findings in both patients. The pneumatoceles resolved rapidly, leaving only minimal scarring. Our cases illustrate the sequential evolution of pneumatoceles in fire-eaters after the inhalation of pyrofluid and documents the rapidity with which the lesions regress. The rare accidental inhalation of pyrofluid in fire-eaters may produce a puzzling clinical and radiographic picture and can be confused with other lung disorders.

Radiographic findings in patients with acquired immunodeficiency syndrome, pulmonary infection, and microbiologic evidence of Mycobacterium xenopi.

The authors studied radiographs and clinical histories of 29 patients with acquired immunodeficiency syndrome, symptoms of pulmonary infection, and simultaneous microbiologic evidence of Mycobacterium xenopi in the respiratory tract. The presence, nature, and distribution of radiographic abnormalities were determined and analyzed in accord with clinical information. In 26 (90%) patients, M. xenopi was the only microorganism that could be isolated. Chest radiographs were normal in 13 patients (45%) and abnormal in 16 patients (55%). Radiographic abnormalities were bilateral in 94% of cases and predominantly involved the lower lobes. Patchy peribronchial opacities (44%) and miliary nodules (24%) were the most common abnormalities. Reticular opacities and parenchymal consolidation were seen in 12% of patients. Pleural effusion was seen in 18% of patients. No patients had cavitations or adenopathy. There was no statistically significant difference regarding the mean age (38.7+/-7.3 years vs. 40.2+/-11.0 years), the duration of clinically evident human immunodeficiency virus infection (2.7+/-1.2 years vs. 2.8+/-1.4 years), and the mean of CD4 cell counts (50.6+/-15.3 cells/ml vs. 47.4+/-15.9 cells/ml) between the patients with and without abnormalities on chest radiographs. In patients with acquired immunodeficiency syndrome, pulmonary infection, and simultaneous microbiologic evidence of M. xenopi, chest radiographs can be normal in a substantial number of cases. When radiographic abnormalities are present, they differ from those seen in patient not infected with the human immunodeficiency virus who had pulmonary infection caused by M. xenopi and from patients with acquired immunodeficiency syndrome and pulmonary infection with nontuberculous mycobacteria other than M. xenopi. Although these findings are not specific, they may be of importance in the imaging of patients with acquired immunodeficiency syndrome, notably in areas where M. xenopi is endemic.

Severity assessment of acute pulmonary embolism with spiral CT: evaluation of two modified angiographic scores and comparison with clinical data.

Spiral computed tomography (CT) has shown promising results in the detection of acute pulmonary embolism. The aim of this study was to investigate whether the severity of acute pulmonary embolism could be quantitatively assessed with spiral CT examinations and to test the potential clinical impact of this information. In a consecutive series of 123 patients screened with spiral CT for suspected acute pulmonary embolism, 31 patients (25%) had evidence of emboli. The severity of pulmonary arterial obstruction in those 31 spiral CT examinations was evaluated by two independent observers using angiographic scores previously described by Walsh (29) and Miller (30), adapted to the needs of spiral CT. Clinical patient subgroups were defined according to oxygen saturation, heart rate, and echocardiographic signs of right ventricular strain. CT severity scores were then correlated to each other and to clinical parameters using the Spearman rank test. Interobserver agreement was calculated using the analysis of variance. Both modified Walsh and Miller scores were readily reproducible and showed interobserver agreements of 0.85 and 0.96, respectively (p = 0.001). Patients with mild and marked clinical abnormalities showed statistically significant differences between CT severity scores. Differences between severity scores of patients with moderate and marked clinical abnormalities were somewhat significant. No significant mean severity score differences were seen between patients with mild and moderate clinical abnormalities. Although correlations of severity scores and detailed clinical parameters within the defined subgroups were moderate to poor, threshold scores greater than 10 (Miller) and greater than 11 (Walsh) always indicated marked clinical abnormalities. The modified scores presented in this study constitute a readily reproducible method for the quantitative assessment of acute pulmonary embolism severity on spiral CT examinations.