Strengths and limitations of coronary angiography with turbo high-pitch third-generation dual-source CT.

AIM: To define practical limitations of diagnostic image quality for recently introduced turbo high-pitch scan mode (THP) in third-generation dual-source computed tomography (CT). MATERIALS AND METHODS: Two hundred and twenty-nine consecutive patients undergoing CT coronary angiography were included in this retrospective single-centre analysis. A contrast-enhanced volume dataset was acquired in THP. Image quality of coronary segments was classified as diagnostic or non-diagnostic by three blinded readers. Segments were stated as non-diagnostic if at least one of three readers could neither exclude nor confirm significant stenoses. Multivariable logistic regression was used to assess relationships between number of non-diagnostic segments and common influencing factors. RESULTS: Median effective radiation dose was 0.6 (interquartile range [IQR], 0.4-0.8) mSv overall and 0.3 (IQR, 0.3-0.4) mSv in the 70 kV subgroup of this middle aged, predominantly pre-obese cohort (age: 61 [IQR, 52-67] years; body mass index [BMI]: 26 [IQR, 23-29] kg/m2) with a low-moderate median Agatston score (AS) 0 (IQR, 0-70). Diagnostic image quality was found in 98.1% of 3,678 coronary segments. AS was independently associated with diagnostic image quality (B=0.34; p=0.02), whereas heart rate, BMI, and presence of arrhythmia were not. The portion of diagnostic coronary segments decreased slightly in obese patients with heart rates >65 beats/min and dropped significantly in patients with an AS >600 (p=0.003). CONCLUSION: THP enables CT coronary angiography with minimal radiation exposure and is most appropriate in non-obese patients with stable sinus rhythm ≤65 beats/min and a calcium score ≤600.

Regional adoptive immunotherapy with interleukin-2 and lymphokine-activated killer (LAK) cells for liver metastases.

A phase lb trial of a novel regional approach to adoptive immunotherapy is reported. Patients with liver metastases received continuous high-dose infusion of interleukin-2 (IL-2) into the splenic artery or intravenous infusion with subsequent transfer of lymphokine-activated killer (LAK) cells into the portal vein or the hepatic artery. Trafficking studies revealed homogeneous distribution of the LAK cells within the liver. The usual side-effects of IL-2 and LAK cells occurred without limiting liver toxicity. One partial (7+ months) and two complete responses (36 and 26+ months) were observed in 9 patients with metastases from cutaneous melanoma. None of 6 patients with metastases from ocular melanoma responded.

[Interventional treatment of hemobilia]. / Interventionelle Behandlung der Hämobilie.

PURPOSE: Aim of the study was to assess the use of embolisation in cases of iatrogenic haemobilia. METHOD: In 18 patients with severe haemobilia after percutaneous biliary system drainage or stent implantation, an embolisation with minicoils (17 x) or gelfoam particles, was performed. To achieve a sufficient vascular obstruction, Histoacryl (4 x) or Ethibloc (1 x) were additionally used in five cases. A transarterial approach was used in 17 cases. In one patient, an approach through the biliary system was possible. RESULTS: In all cases, the bleeding source was identified (5 false aneurysms, three biliary leaks, 9 irregularities at the junction of the artery and drainage catheter, 1 multiple collaterals at the proximal end of the stent). In 17 out of 18 cases, haemorrhage ceased definitely. In one case of a patient with pancreas carcinoma and obstruction of the portal vein as well as a simultaneous high grade stenosis of the hepatic artery propria, it was only possible to embolise small collaterals to avoid liver necrosis. This resulted in an incomplete bleeding of control. An infected haematoma was the only complication. It was treated by drainage over 10 days. During an observation period ranging approximately 7.6 months, 10 of the patients died due to their basic illness. CONCLUSION: Embolisation is an effective procedure in the treatment of haemobilia, with a low complication rate.

[The role of embolization treatment of acute hemorrhage]. / Zum Stellenwert der Embolisationsbehandlung bei akuten Blutungen.

137 arteries of 95 patients were treated by transcatheter embolization for massive haemorrhage using Ethibloc, Gelfoam, wire coils and Tissucol (Fibrinogen + Thrombin). The bleeding was secondary to trauma in 23 patients, to neoplasms in 16 patients and to vascular malformations or chronic inflammatory processes in 41 cases. 15 patients were treated for iatrogenic bleeding following surgery. Bleeding was referred to haemoptysis (n = 27), pelvic (n = 24), renal (n = 16) or gastrointestinal haemorrhage (n = 13) as well as several other diseases (n = 15). Most patients were poor surgical candidates. The overall bleeding control rate was 89.5% with a incidence of recurrent bleeding in 14 out of 95 patients (14.7%) treated by re-embolization or surgery. 6 patients died (6.3%) due to intractable haemorrhage, 4 patients (4.2%) died of complications related to embolization procedure (4 x bowel infarction!) and 33 patients (34.7%) died of procedure-unrelated causes such as myocardial infarction, trauma, malignancy or other underlying diseases. 58 patients (61.1%) are still alive (follow-up 16.2 +/- 4.8 months). Significant complications (5.3%) included bowel necrosis (4x) and ischaemia of the spinal cord with incomplete paralysis in one patient. One patient suffered thrombosis of the common iliac artery due to angiography. On the basis of our results, peripheral embolization using Ethibloc can be recommended as palliative treatment for devascularisation of bleeding tumours. Satisfactory results are obtained in haemoptysis, renal and pelvic haemorrhage, but gastrointestinal bleeding should not be occluded by means of Ethibloc because of its considerable risk of bowel infarction.

[The hydro-MRT of chronic inflammatory bowel diseases]. / Hydro-MRT chronisch entzündlicher Darmerkrankungen.

PURPOSE: Evaluation of hydro-MRI in the diagnosis of chronic inflammatory bowel disease (IBD). MATERIAL AND METHODS: 33 patients with suspected Crohn's disease or ulcerative colitis were studied prospectively. After distension of the colon by a rectal enema, breathhold MR imaging was performed during bowel relaxation. Results were compared to the clinical diagnosis, endoscopy, barium studies and histopathology. RESULTS: 24/24 patients with active Crohn's disease were correctly diagnosed by MRI. Conversely, MRI was positive in only 2/5 patients with ulcerative colitis. In 5 patients the presence of IBD was excluded. There were no false positives. CONCLUSION: Hydro-MRI is a very reliable modality in the diagnosis of Crohn's disease. In the differentiation of Crohn's disease from ulcerative colitis, hydro-MRI seems to be a promising imaging procedure.

[TIPSS: 10 years of clinical experience]. / TIPSS: 10 Jahre klinische Erfahrung.

UNLABELLED: To demonstrate and document 10 years of clinical experience gathered by us with TIPSS and to discuss achievements, problems and outlook. MATERIAL AND METHODS: The analysis is based on the following parameters: portosystemic gradient; morphological delineation of the portal circulation; determination of the portal perfusion fraction (PPF) and the total liver perfusion (GLP); arterial flow changes; hepatic encephalopathy; incidence of restenotic shunt occlusion and recurrent variceal bleeding. RESULTS: Variceal filling was widely reduced by TIPSS, and significantly reduced portal liver perfusion as assessed morphologically and rheologically. However, there was an immediate onset of compensated liver perfusion by increased arterial inflow. Total liver perfusion did not change significantly. In TIPSS portal decompression was readily achieved, the portosystemic gradient dropping from an average of 24 mm Hg to 10.5 mm Hg. In our series we could not demonstrate an increased incidence of hepatic encephalopathy during the 30-day post-TIPSS period. Early mortality was 4% and early rebleeding rate 3%. The 12-month re-intervention rate based on an invasive portography follow-up protocol was 76%, and the 24-month re-intervention rate was 90%. The definite occlusion rate was below 5%. Beyond a follow-up time span of 24-months the necessity for re-intervention dropped significantly: less than one-third of our patients required some sort of re-intervention. CONCLUSION: The concept of TIPSS represents an individually calibrated H-shunt. The significant reduction of post-TIPSS portal perfusion appears to be compensated by increased arterial inflow. This is reflected by an invasive flow measurement results and by the clinical results. Lethality of TIPSS is low mostly as a result of a refined technique, careful patient selection, follow-up care and meticulous shunt surveillance.

[Modified presentation of a lung embolism by a rare variant of pulmonary vein anomalous connection]. / Modifizierte Präsentation einer Lungenembolie durch eine seltene Variante der Lungenvenenfehlmündung.

Partial anomalous pulmonary venous return of the left lung is an extremely rare cardiovascular abnormality. Mostly, this rare entity is found incidentally when patients undergo angiography of the pulmonary artery because of suspected pulmonary embolism. In this case hemodynamic data obtained by a swan ganz catheter suggested a cardiovascular abnormality presenting as left-right shunt. Surgical therapy of anomalous venous return of the left lung is only required if volume overload of the left ventricle occurs.

[Portal hypertension and percutaneous transjugular portasystemic stent shunt]. / Portale Hypertension und percutan transjugulär angelegte portosystemische Stent-Shunts (TIPSS).

This paper reports 1) the historic development of TIPSS, the transjugular intrahepatic portosystemic stent shunt from experimental evaluation to clinical realization. 2) The evolution of the instrumental technique during a period of 6 years of clinical applications is described in detail. 3) Results based on 204 consecutive procedures are demonstrated: e.g. the early technical success defined as successful completion of the procedure and 30-day survival was 95%; the clinical success defined as technically successful procedure and no rebleeding during the first 30 days was 83%, the 30-day mortality rate was 6.3%; the 30-day encephalopathy rate was 14.1%; the one-year re-bleeding rate was 11%; the one-year survival rate was 74%, the 3-year survival rate was 41%. 4) Problems of the TIPSS procedure are discussed including a 3-months re-stenosis rate of 46% and a cumulative one-year re-stenosis rate of 84% which requires correction by interventional procedures such as shunt dilatation or additional vascular stent placement. 5) Limitations and indications of TIPSS are elucidated based on hemodynamic and functional aspects of liver cirrhosis.

[Repetitive immuno-embolization of inoperative liver metastases of renal cell carcinoma. Method characterization and preliminary results]. / Repetitive Immunembolisation inoperabler Lebermetastasen beim Nierenzellkarzinom. Methodencharakterisierung und vorläufige Ergebnisse.

Interleukin 2 (IL2)-based immunotherapy is effective in a subgroup of patients with metastatic renal cancer, but cure from liver metastases is very rare and even the selection of patients to be treated is very much limited by the toxicity of IL2. To reduce this toxicity and to augment the efficacy of intrahepatic IL2 application, a protocol of combined rIL2 (3 mg/day) and Lipiodol (2-5 ml/day according to tumour size), via a catheter inserted percutaneously into the hepatic artery, was implemented. As an adverse reaction, moderate fever (WHO) grade I and II was noted. A partial remission was seen in one patient and stable disease in four patients over a period of 2-6 years (median 32.2 month). It seems that immuno-embolisation of otherwise intractable liver metastases of renal cancer is well tolerated and its efficacy may be augmented by optimisation of the therapeutic protocol.

[Transjugular intrahepatic portasystemic stent shunt (TIPSS). Technique of implantation]. / Der transjuguläre intrahepatische portosystemische Stentshunt (TIPSS). Technik der Implantation.

Implantation of a transjugular intrahepatic portosystemic stent shunt (TIPSS) is guided by ultrasound and fluoroscopy. Today this stent is clinically established as a concept of "minimal invasive therapy" to treat recurrent variceal bleeding in patients with portal hypertension. We describe its technical steps in detail, giving the materials used. "Intraoperative" and "postoperative" monitoring and the typical features of an ideal shunt are described.

[Long-term results after TIPSS with the Palmaz stent]. / Langzeitergebnisse nach TIPSS mit dem Palmaz-Stent.

Since our first clinically successful TIPSS procedure in 1988 numerous steps to improve the safety and methodology have helped to increase the technical and clinical success while the rate of complications could be significantly reduced. In our series of more than 200 patients the technical success rate is more than 95% and the early clinical success rate (< 30 days after TIPSS) 89%, respectively. Early shunt occlusion was found in 1.5% of our patients. 3 months after TIPSS, however, transjugular portography reveals significant shunt stenosis in 46% needing either shunt re-dilatation or additional stent placement. This relatively high rate of re-intervention is being significantly reduced during the further follow-up with a frequency of 17% at a 6 month interval and 6% at a 12 month interval, respectively. The need for re-intervention is strongly associated with liver function and the patients' coagulation status: Child's A patients needed re-intervention substantially more often than those in stage B or C at each given follow-up interval. The decreasing need for re-intervention over time appears to be associated with the formation of an endothelial cell layer on the surface of the shunt tract.

[Stent angioplasty of the intrarenal aorta and aortic bifurcation. Clinical and angiographical results of a prospective study]. / Stentangioplastie der infrarenalen Aorta und der Aortenbifurkation. Klinische und angiographische Ergebnisse einer prospektiven Studie.

PURPOSE: The study was carried out to evaluate clinical and technical success, early and late complications and patency rates after stent angioplasty of atherosclerotic stenoses and occlusions of the infrarenal abdominal aorta and aortic bifurcation. PATIENTS AND METHODS: This was a prospective study in 20 consecutive patients treated by implantation of balloon-expandable stents. All patients were followed-up after 6 and 12 months and at yearly intervals thereafter by physical examination, Doppler sonography and angiography. RESULTS: Nineteen of 20 patients had clinical and technical success. In two patients clinically relevant complications occurred. During a mean observation time of 19 months (range 3-51 months) restenosis occurred in one stent after 15 months and was successfully treated by balloon angioplasty. Two patients became symptomatic again due to new atherosclerotic disease. CONCLUSIONS: Percutaneous stent angioplasty of the infrarenal aorta and aortic bifurcation yields high immediate and mid-term success rates with primary patency of 90% and secondary patency of 95%. These results are slightly better than those with balloon angioplasty, but the limited number of patients in our and others' studies does not yet justify general recommendations.

Immunological mechanisms giving rise to latency of herpes simplex virus in the spinal ganglia of the mouse.

In the model of genital herpes simplex virus (HSV)-infection of mice, early latency could be induced by passive immunization with HSV-specific antibodies and, to a lesser degree, by adoptive transfer of immune lymphocytes prepared from spleen and draining lymph nodes of genitally infected syngeneic mice. Conversely, spontaneously occurring latency was inhibited by treatment of the animals with cyclophosphamide (Cph) and, to a lesser degree, with cyclosporin A (CyA). Whereas the effect of CyA could be compensated by passively administered HSV-specific antibodies, that of Cph could not. Apparently specific antibodies cooperate with a non-specific proliferating cell type, probably macrophages and/or NK-cells, as could be demonstrated by significantly reduced antibody effect in silica-treated mice. Moreover, F(ab)2 fragments, in contrast to complete antibody molecules, were inactive. HSV-specific antibodies and also immune lymphocytes had little effect on virus production in the mucous membranes, immune lymphocytes being at least as active as antibodies. It is therefore not probable that latency is induced by attenuation of the peripheral disease. It can rather be concluded that the neuron itself is the target for the action of specific antibodies, cooperating in turn with macrophages and/or NK cells.

[Lymphoma in childhood]. / Lymphome im Kindesalter.

Manifestation of childhood Hodgkin's disease and Non-Hodgkin's lymphoma differ, especially in the latter, from those in adults. Extranodal involvement is seen even more frequently in childhood Non-Hodgkin's lymphomas than in adults. This article reviews the radiological findings in malignant lymphomas in children, explains the differences in the manifestation of Hodgkin's lymphomas, of different subtypes and of the malignant lymphomas in adults. The problems in diagnosis of organ manifestation and special problems of diagnostic imaging procedures in children are discussed.

[Malignant lymphoma in childhood. Ultrasound diagnosis]. / Maligne Lymphome im Kindesalter. Ultraschalldiagnostik.

The sonographic diagnosis of malignant lymphoma in childhood is described. Malignant lymphomas are sonographically relatively uniform: initial enlargement of the lymph nodes and organs involved and disturbance of normal echo texture by mainly hypoechoic lesions can be found. Generally, four sonographic patterns of infiltration are described: diffuse, small nodular, large nodular and bulky type. Secondary, tumor-related or inflammatory complications (e.g. dislocation or compression of vessels, thoracic inlet syndrome, venous thrombosis, ileus, urinary retention, abscess and effusion) can be sonographically evaluated. Response to therapy correlates with normalization of size and echo texture and recovery from tumor-related complications. Differential diagnosis with ultrasound is based on the topographic distribution and echo pattern of infiltration and, with certain restrictions, on the echogenicity of lesions and perfusion feasible with Doppler sonography. The primary diagnosis has to be established histologically.

Diagnostic accuracy in remote expert consultation using standard video-conference technology.

An international multicenter study (Germany, Sweden, and Switzerland) was performed to investigate the feasibility and diagnostic reliability of standard video-conferencing (VC) technology for remote expert consultation in radiology. Three high-spatial-resolution films (hand-bone, mammography, chest) and two low-spatial-resolution image sets (liver CT and MRI) were studied (total 446 images taken from different examinations). The images were recorded by a video camera, transmitted via public broadband networks, and displayed on a video monitor. The resolution of the recorded images varied from 2.4 lp/mm to 4.8 lp/mm at maximum zoom. After 3-4 months, the images were reexamined using conventional light-box reading. Diagnostic reliability was evaluated by receiver operating characteristics (ROC) analysis. With video conferencing, there was a noticeable loss of diagnostic accuracy for the high-spatial-resolution films, whereas for liver CT and liver MRI images VC reading seemed to be satisfactory (average area value difference < 0.02).

[CT-guided puncture]. / CT-gesteuerte Punktionen.

Sonographic and CT-guided punctures allow the evaluation of suspected lesions in the head, thorax, abdomen, retroperitoneum and skeletal system. The size of the lesion to be evaluated determines the size and the diameter of the puncture needle. The quantity of the material obtained will be defined by the diameter of the needle, i.e. fine-needle biopsy is more adequate for cytological than for histological evaluation. Strict adherence to the indications and contraindications for puncture and painstaking performance of the procedure go a long why towards minimizing the complications. The advantage of CT-guided puncture, in contrast to an ultrasound-guided procedure, is visualization during the puncture procedure free from overshadowing. This permits punctures of lesions located deep in the thorax or the abdomen which are overshadowed by the lungs, by air in the small or large bowel or by bone structures. Moreover, this technique yields much more information about the tissues and organs surrounding the suspected lesion. This information is much more investigator-related with ultrasound-guided puncture. Therefore, the CT-guided puncture has become mandatory in the evaluation of suspected lesions. Moreover, using the same technique, percutaneous drainage of fluids in the interpleural space, abscesses in organs, hematomas, lymphoceles and urinomas; ablation of metastases; and sympathicolysis can be carried out. CT-guided puncture thus changes from a minimally invasive diagnostic procedure to a minimally invasive therapy.

[Postoperative MRI morphology of the anterior cruciate ligament after primary ligament suture or ligament-plasty. A prospective study of 50 patients]. / Die postoperative MRT-Morphologie des vorderen Kreuzbandes nach primärer Bandnaht oder Bandplastik. Eine prospektive Studie an 50 Patienten.

AIM: Identification of typical postoperative change after anterior cruciate ligament reconstruction (sutures, tendon grafts) and comparison with clinical tests and ultrasound. PATIENTS AND METHODS: 50 patients with anterior cruciate ligament ruptures were examinated with MRI (1.0 T, surface coil, sagittal T1-3DFT-Fast and sagittal spin-echo), US and clinical function tests (Lachmann, pivot-shift, anterior drawer test). RESULTS: In 19 of 21 patients with continuous low-intensity ligament structures in the MRI, knee stability was very good or good in the clinical tests and US. In 17 of 20 patients with a diagnosis of partial rupture at MRI, we also found a stable knee. 5 of 7 patients with the MRI-signs of ligament rupture showed knee stability at US and clinical tests. Furthermore, at MRI we found minor effusions in 10 patients, meniscus tears in 8 patients and ligament impingement in 2 patients. CONCLUSION: MRI is a valuable method for evaluating and assessing anterior ligament reconstructions. We found a good correlation between the continuous low-intensity ligaments at MRI and knee-stability. In contrast there is a bad correlation between discontinuous ligament structures at MRI and clinical stability of the knee. MRI seems to provide more information than US and clinical tests (for example: minor effusion, meniscus tears, ligament impingement, bone lesions).