[Systematics of shoulder instability]. / Systematik der Schulterinstabilität.

Shoulder instability is defined as a symptomatic abnormal motion of the humeral head relative to the glenoid during active shoulder motion. Glenohumeral instabilities are classified according to the causative factors as the pathogenesis of instability plays an important role with respect to treatment options. Instabilities are classified into traumatic and atraumatic instabilities as part of a multidirectional instability syndrome and into microtraumatic instabilities.For diagnostics plain radiographs ("trauma series") are performed to document shoulder dislocation and its successful repositioning. Direct magnetic resonance (MR) arthrography is the most important imaging modality for delineation of the different injury patterns of the labral-ligamentous complex and bony structures. Monocontrast computed tomography (CT) arthrography with the use of multidetector CT scanners represents an alternative imaging modality; however, MR imaging should be preferred in the work-up of shoulder instabilities due to the mostly younger age of patients.

[Surgical therapy of segmental jejunal, primary intestinal lymphangiectasia]. / Die operative Therapie einer segmentalen, primären intestinalen Lymphangiektasie des Jejunums mit ausgeprägtem Chylaskos.

Primary intestinal lymphangiectasia (PIL) is a protein-losing, exsudative gastroenteropathy causing lymphatic obstruction. Diagnosis depends on clinical examination and histological findings. Conservative treatment modalities include a low-fat diet and enteral nutritional therapy in order to reduce enteric protein loss and to improve fat metabolism. Other treatment options consist of administration of antiplasmin or octreotide to lower lymph flow and secretion. We report on a 58-year-old patient who underwent exploratory laparotomy due to a worsening physical status, recurrent chylaskos and leg oedema under conservative dietary therapy. Intraoperative findings showed a typical PIL of the jejunum about 20 cm distal to the Treitz's ligament. Histological examinations confirmed this diagnosis. One year after segmental small bowel resection (105 cm) with end-to-end anastomosis the patient is healthy, free of symptoms, has gained weight and his serum protein level has increased. Intraabdominal ascites and leg oedema have not reoccurred since.

Late Gadolinium Enhancement Cardiac Magnetic Resonance Imaging: From Basic Concepts to Emerging Methods.

BACKGROUND: Late gadolinium enhancement (LGE) is a widely used cardiac magnetic resonance imaging (MRI) technique to diagnose a broad range of ischemic and non-ischemic cardiomyopathies. Since its development and validation against histology already more than two decades ago, the clinical utility of LGE and its span of applications have increased considerably. METHODS: In this review we will present the basic concepts of LGE imaging and its diagnostic and prognostic value, elaborate on recent developments and emerging methods, and finally discuss future prospects. RESULTS: Continuous developments in 3 D imaging methods, motion correction techniques, water/fat-separated imaging, dark-blood methods, and scar quantification improved the performance and further expanded the clinical utility of LGE imaging. CONCLUSION: LGE imaging is the current noninvasive reference standard for the assessment of myocardial viability. Improvements in spatial resolution, scar-to-blood contrast, and water/fat-separated imaging further strengthened its position. KEY POINTS: · LGE MRI is the reference standard for the noninvasive assessment of myocardial viability. · LGE MRI is used to diagnose a broad range of non-ischemic cardiomyopathies in everyday clinical practice.. · Improvements in spatial resolution and scar-to-blood contrast further strengthened its position. · Continuous developments improve its performance and further expand its clinical utility. CITATION FORMAT: · Holtackers RJ, Emrich T, Botnar RM et al. Late Gadolinium Enhancement Cardiac Magnetic Resonance Imaging: From Basic Concepts to Emerging Methods. Fortschr Röntgenstr 2022; 194: 491 - 504.

Area at risk and viability after myocardial ischemia and reperfusion can be determined by contrast-enhanced cardiac magnetic resonance imaging.

BACKGROUND/AIMS: Clinical differentiation between infarcted and viable myocardium in the ischemic area at risk is controversial. We investigated the potential of contrast-enhanced cardiac magnetic resonance imaging (ceCMRI) in determining the area at risk 24 h after ischemia. METHODS: Myocardial ischemia was induced by percutaneous coronary intervention of the left anterior descending coronary artery in pigs. Coronary occlusion time was 30 min in group A, which caused little myocardial infarction and 45 min in group B, which led to irreversible damage. 24 h after reperfusion ceCMRI was performed at 2 and 15 min after administration of gadolinium-diethylenetriamine pentaacetic acid. The area at risk was determined by intravenous injection of Evans blue and myocardial viability by triphenyltetrazolium-chloride staining. RESULTS: The signal-intense areas at 2 and 15 min after contrast administration matched the area at risk in groups A and B. Nonviable myocardium in group A was overestimated (14-15%) while good agreement was present in group B. CONCLUSION: The area at risk of reperfused ischemic myocardium can be determined by ceCMRI 24 h after coronary recanalization. This type of information might have relevant clinical implications in the treatment and stratification of patients with acute coronary syndrome in particular after surgical interventions.

Multidetector Computed Tomography Angiography (MD-CTA) of Coronary Artery Bypass Grafts - Update 2017.

BACKGROUND: Coronary artery bypass grafting (CABG) is still an important therapeutic approach in the treatment especially of advanced coronary artery disease. In this study, we elucidate the current role of multidetector computed tomography angiography (MD-CTA) in imaging patients after CABG surgery. METHOD: This study is based on recent reports in the literature (2007 - 2016) on imaging of CABG using 64-slice MD-CT scanners and beyond. We included 13 reports that compared ECG-gated MD-CTA with conventional invasive coronary angiography (ICA) as the reference standard for the assessment of graft patency and for the detection of > 50 % stenoses. These studies had to provide absolute values for true-positive, true-negative, false-positive and false-negative results or at least allow calculation of these numbers. In total, 1002 patients with 2521 bypass grafts were the basis for this review. RESULTS AND CONCLUSION: The sensitivity and specificity for the assessment of graft patency or the detection of > 50 % graft stenosis were 97.2 % and 97.5 %, respectively. The negative and positive predictive values were 93.6 % and 99 %, respectively. By using prospective ECG-gating and an increasing pitch factor, the radiation dose exposure declined to 2.4 mSv in the latest reports. ECG-gated MD-CTA provides a fast and reliable, noninvasive method for assessing patients after CABG. The most substantial benefit of the newest CT scanner generations is a remarkable reduction of radiation dose exposure while maintaining a still excellent diagnostic accuracy during recent years. KEY POINTS: · MD-CTA using 64-slice MDCT scanners and beyond is a reliable, noninvasive method for evaluating CABGs.. · Technical advances such as prospective ECG-gating, iterative reconstruction algorithms and high-pitch scanning lead to a remarkable drop-down in radiation dose exposures as low as 2.4 mSv.. · Despite significant dose reductions, MD-CTA could maintain a high diagnostic accuracy in evaluating CABGs in recent years.. CITATION FORMAT: · Jungmann F, Emrich T, Mildenberger P et al. Multidetector Computed Tomography Angiography (MD-CTA) of Coronary Artery Bypass Grafts - Update 2017. Fortschr Röntgenstr 2018; 190: 237 - 249.

["Dead or alive?": how and why myocardial viability imaging by cardiac MRI works]. / "Tot oder lebendig?": Wie und warum myokardiale Vitalitätsdiagnostik mit MRT funktioniert.

Myocardial viability imaging by contrast-enhanced MRI has supported the broad acceptance of cardiac MRI as a valuable clinical tool in cardiology over the last few years. The late enhancement (delayed enhancement, late gadolinium enhancement) technique has emerged as an easy-to-perform and robust method for identifying and quantifying myocardial scars. In the condition of acute myocardial infarction, MRI offers important prognostic information regarding anticipated left ventricular changes ("remodeling") and future cardiac events. In coronary artery disease patients with chronic infarction, the extent of late enhancement reliably predicts the outcome of global and regional left ventricular function after revascularization. In particular, CAD patients with severely impaired left ventricular function benefit from preoperative viability imaging before bypass surgery. The present paper describes the definitions and physiology of viable and non-viable myocardium as well as the pathophysiologic basis of late enhancement. The process from the correct setting of imaging protocols via the interpretation of late enhancement images to the stating of the correct diagnosis and estimation of viability is followed. The background of the successful development of the late enhancement method towards the new reference standard in myocardial viability imaging is described.

Assessment of the distal anastomosis of coronary artery bypass grafts with a 2D T2-weighted turbo spin echo sequence and correlation to conventional coronary angiography.

OBJECTIVE: The aim of the study was to evaluate the patency of the distal anastomoses of coronary artery bypass grafts and to detect graft stenoses and occlusions with a magnetic resonance (MR) spin echo sequence. PATIENTS AND METHODS: One hundred and eighty-five patients with 481 distal anastomoses were examined with a 1.5 T MR scanner and coronary angiography. A 2-dimensional T2-weighted breath-hold half-Fourier acquisition single-shot turbo spin echo sequence (Haste) was performed. All images were evaluated independently by a radiologist and cardiologist and compared to the conventional coronary angiography. The observers were blinded to the coronary angiography findings, but informed in regard to the surgical graft anastomosis. RESULTS: With the Haste sequence, 76% of the distal anastomoses were recognized (368/481). Forty-five of 52 (87%) stenoses and all occlusions were identified. The sensitivity and specificity for the evaluation of the distal anastomosis with the spin echo sequence was 87% and 96%. Twenty-four percent of the distal anastomoses were not identified due to a poor image quality or motion artefacts. CONCLUSION: Using the Haste sequence, a reliable assessment of graft patency of the distal anastomosis is possible. Further improvements of the spatial resolution and the image quality are necessary to recommend this MR technique for routine clinical use.

The benefit of multislice CT in the emergency room management of polytraumatized patients.

The early treatment of polytraumatized patients needs an effective and standardized approach. Reducing time requirements for the primary diagnostic evaluation is a major concern in the early phase of polytrauma management. Multislice-CT (MSCT) is a quick and reliable method for the initial diagnostic evaluation. Computed tomography provides more detailed and more consistent information than conventional radiography. It has the great advantage of allowing rapid examination of the head, vertebral column, chest, abdomen and pelvis during one single examination. The CT-suite needs to be adequately equipped for resuscitation and reanimation, which is done parallel to the radiological investigations. Since polytrauma management is based on a multidisciplinary approach characterized by a coordinated interaction between trauma surgeons, anaesthesiologists and radiologists, members of all involved disciplines need adequate teaching. Guidelines and algorithms contribute to optimize the early management.

[Contribution of early systole to total antegrade flow volume in breath-hold phase-contrast flow measurements]. / Anteil des frühen systolischen Flussanstiegs am antegrad fliessenden Gesamtvolumen bei Phasenkontrast-Flussmessungen in Atemanhaltetechnik.

PURPOSE: To evaluate the contribution of early systole for the assessment of antegrade aortic flow volume by breath-hold velocity-encoded magnetic resonance (MR) flow measurements. MATERIALS AND METHODS: Expiratory breath-hold fast low-angle shot (FLASH) phase-contrast flow measurements (temporal resolution tRes 61 msec, shared phases) perpendicular to the proximal ascending aorta and short axis true fast imaging with steady-state precession (TrueFISP) cine MR ventriculometry (tRes 34.5 msec) were performed in ten healthy male volunteers on a 1.5 T MR system (Sonata, Siemens Medical Solutions). Antegrade aortic flow volume (AFV) and left ventricular stroke volume (LV-SV) were evaluated using Argus Ventricular Function and Argus Flow Software, version MR 2002B (Siemens Medical Solutions). A beta release of Argus Flow MR 2004A allowed interpolation of the flow up-slope during early systole to the preceding R-wave trigger. The respective intraindividual median differences between the AFV of each flow evaluation and LV-SV as well as between both AFV measurements were calculated and compared using the sign test for paired samples. RESULTS: Non-interpolated AFV significantly deviated from LV-SV (p = 0.006), underestimating the latter by 13.1 mL (13 %). Interpolating aortic flow during early systole significantly increased AFV by 10.8 mL (13 %) compared to the flow evaluation which did not take early systole into account (p = 0.006). AFV with interpolation of early systolic flow agreed well with LV-SV (median difference - 3.0 mL or - 3 %, respectively), and no significant difference between these measurements was found (p = 1.0). CONCLUSION: Flow during early systole contributes substantially to total forward flow volume in the ascending aorta. Interpolation of the early systolic up-slope is therefore recommended for the evaluation of breath-hold phase-contrast flow measurements.

[Systematic analysis of the geometry of a defined contrast medium bolus--implications for contrast enhanced 3D MR-angiography of thoracic vessels]. / Systematische Analyse der Geometrie eines definierten Kontrastmittelbolus -- Implikationen für die kontrastmittelverstärkte 3D-MR-Angiographie thorakaler Gefässe.

PURPOSE: Little is known about the dispersion of a defined contrast bolus during its passage through the heart and pulmonary vasculature. The purpose of this study was to analyze factors influencing a defined contrast bolus for ce-MRA of thoracic vessels. MATERIALS AND METHODS: For analysis of bolus geometry, an ECG-gated saturation-recovery Turbo-Flash sequence with a TI of 20 msec was used. It was acquired axially at the level of the pulmonary trunc, so that with one data acquisition a curve analysis was possible in the ascending and descending aorta, and in the pulmonary trunc. Twenty-nine patients received 3 ml of Gd-DTPA diluted with saline to a total of 20 ml. Contrast injection was done using a MR compatible power injector with injection rates varying between 1, 2 and 4 ml/sec. Each injection was followed by a saline flush of 20 ml with the same injection rate and mode. Cardiac function was assessed by cine imaging, and phase contrast measurements. After normalization to baseline signal intensity (SI), bolus curves were fitted using a gamma-variate fit and peak signal intensity (peak SI), time-to-peak (TP), upslope, mean transit time (MTT) and dispersion of the contrast bolus were calculated. Furthermore, T (1) and [Gd] in the experimental setting were calculated as follows: T (1) = T (1 o)/ ln [SI/SI (0)], and [Gd] (exp) = [1/T (1) - 1/T (1 o)]/ R (1.) They were then extrapolated [Gd] to clinical conditions by [Gd] (clin) = [Gd] (exp) . 10/1.5, and minimal blood T (1) by T (1)(clin) = 1 / [1/T (1 o) + R (1) [Gd] (clin)]. RESULTS: With increasing injection rate, there was a significant decrease (p < 0.001) of MTT in all target vessels. However, this decrease was not linear: a 4-fold increase in injection rate lead to a 2-fold decrease in MTT e. g. in the ascending aorta. MTT was significantly shorter in the pulmonary trunc compared with that in the ascending and descending aorta (p < 0.001), regardless of injection rate (p < 0.001). Vice versa, dispersion of the contrast bolus was significantly lower in the pulmonary trunc, and increased with higher injection rates. There was no clinically relevant difference in minimal blood T (1) between the different target vessels, for clinical conditions extrapolated values ranged between 20 und 79 msec. Heart function parameters only had a minor influence of bolus curve parameters. CONCLUSION: Analysis of bolus geometry enables determination of transit times of a defined contrast bolus through a defined target vessel in the thoracic cavity. Bolus geometry is mainly determined by injection parameters, cardiac function is of minor importance. Dispersion of contrast bolus and MTT increase from the pulmonary trunc to the ascending aorta. The knowledge of these facts may help optimizing of injection parameters and the total amount of contrast agent for contrast-enhanced MRA of thoracic vessels.

Cardiac MR enables diagnosis in 90% of patients with acute chest pain, elevated biomarkers and unobstructed coronary arteries.

OBJECTIVE: To assess the diagnostic value of cardiac MRI (CMR) in patients with acute chest pain, elevated cardiac enzymes and a negative coronary angiogram. METHODS: This study included a total of 125 patients treated in the chest pain unit during a 39-month period. Each included patient underwent MRI within a median of 3 days after cardiac catheterization. The MRI protocol comprised cine, oedema-sensitive and late gadolinium-enhancement imaging. The standard of reference was a consensus diagnosis based on clinical follow-up and the synopsis of all clinical, laboratory and imaging data. RESULTS: MRI revealed a multitude of diagnoses, including ischaemic cardiomyopathy (CM), dilated CM, myocarditis, Takotsubo CM, hypertensive heart disease, hypertrophic CM, cardiac amyloidosis and non-compaction CM. MRI-based diagnoses were the same as the final reference diagnoses in 113/125 patients (90%), with the two diagnoses differing in only 12/125 patients. In two patients, no final diagnosis could be established. CONCLUSION: CMR performed early after the onset of symptoms revealed a broad spectrum of diseases. CMR delivered a correct final diagnosis in 90% of patients with acute chest pain, elevated cardiac enzymes and a negative coronary angiogram. ADVANCES IN KNOWLEDGE: Diagnosing patients with acute coronary syndrome but unobstructed coronary arteries remains a challenge for cardiologists. CMR performed early after catheterization reveals a broad spectrum of diseases with only a simple and quick examination protocol, and there is a high concordance between MRI-based diagnoses and final reference diagnoses.

Contributions of dynamic phosphorus-31 magnetic resonance spectroscopy to the analysis of muscle fiber distribution.

RATIONALE AND OBJECTIVES: In high-performance athletes, conclusions regarding the muscle fiber distribution were to be drawn from dynamic 31phosphorus magnetic resonance spectroscopy (31P MRS). METHODS: Eleven volleyball players (V), eight bodybuilders (B), and 22 nonathletic volunteers (N) were examined by dynamic 31P MRS. During rest, exhaustive exercise, and recovery, respectively, up to 60 consecutive phosphorus spectra of the quadriceps muscle were acquired by "time series" in 36 s each. Two main spectroscopic approaches to the spectroscopic analysis of muscle fiber distribution were applied: evaluation of the ratio Pi/PCr at rest and the computer-assisted analysis of the Pi-peak at its exercise-induced line width maximum. RESULTS: At rest, the bodybuilders showed a significant lower Pi/PCr (0.07 +/- 0.03), in comparison with the volleyball players (0.11 +/- 0.03) and the nonathletic volunteers (0.11 +/- 0.02). The computer-assisted analysis of the Pi-peak at its line width maximum revealed a significantly lower pH of both of the subpeaks in the bodybuilders [6.30 versus 6.37 (V) and 6.38 (N); 6.89 versus 6.92 (V, N)], whereas the volleyball players provided the largest proportion of oxidative muscle fibers (68%), compared to bodybuilders (64%) and nonathletic volunteers (59%). A correlation between the ratio Pi/PCr and the area of the subpeak with the high pH (representing oxidative fibers) could not be demonstrated. CONCLUSIONS: Spectroscopic results during rest and exercise may be influenced by the muscle fiber distribution of the respective volunteer. The applied spectroscopic approaches to the analysis of muscle fiber composition are not compatible with each other; depending on the applied method, the classification of a muscle fiber as type I or type II fiber may change. The influence of physiologic factors like muscle fiber distribution on spectroscopic results has to be considered in the interpretation of pathological conditions.

Contrast-enhanced MRI of the lung.

The lung has long been neglected by MR imaging. This is due to unique intrinsic difficulties: (1) signal loss due to cardiac pulsation and respiration; (2) susceptibility artifacts caused by multiple air-tissue interfaces; (3) low proton density. There are many MR strategies to overcome these problems. They consist of breath-hold imaging, respiratory and cardiac gating procedures, use of short repetition and echo times, increase of the relaxivity of existing spins by administration of intravenous contrast agents, and enrichment of spin density by hyperpolarized noble gases or oxygen. Improvements in scanner performance and frequent use of contrast media have increased the interest in MR imaging and MR angiography of the lung. They can be used on a routine basis for the following indications: characterization of pulmonary nodules, staging of bronchogenic carcinoma, in particular assessment of chest wall invasion; evaluation of inflammatory activity in interstitial lung disease; acute pulmonary embolism, chronic thromboembolic pulmonary hypertension, vascular involvement in malignant disease; vascular abnormalities. Future perspectives include perfusion imaging using extracellular or intravascular (blood pool) contrast agents and ventilation imaging using inhalation of hyperpolarized noble gases, of paramagnetic oxygen or of aerosolized contrast agents. These techniques represent new approaches to functional lung imaging. The combination of visualization of morphology and functional assessment of ventilation and perfusion is unequalled by any other technique.

[Duplex sonography of abdominal vessels]. / Duplexsonographie abdomineller Gefässe.

Duplex sonography is a non-invasive procedure which permits the determination of flow velocity and direction in visceral vessels. Results in 50 normals have shown that small arteries can be evaluated in about 50% of cases. The portal venous system can be demonstrated in all cases; average flow velocity and volume is 15.2 +/- 2.8 cm/s and 694 +/- 230 ml/min, corresponding with the values obtained by invasive methods. Clinical application for duplex examinations can be found in portal hypertension, varices, thromboses, aneurysms and transplant kidneys.

[Cohen's kappa or McNemar's test? A comparison of binary repeated measurements]. / Cohen's kappa oder McNemar's Test? Der Vergleich binärer Mehrfachbefunde.

This article intends to illustrate the combination of McNemar's significance test and Cohen's kappa coefficient in the comparison of repeated binary measurements. Both methods are standard statistical tools of major relevance for the evaluation and comparison of clinical imaging methods and thus have an impact on the corresponding publications. The interpretation of results obtainable with these methods will be illustrated to facilitate their use based on recent statistical software. Examples will further outline limitations and possible pitfalls in their application to clinical data.

[Contrast-enhanced MR angiography of abdominal vessels using a 1.0 T system]. / Kontrastverstärkte MR-Angiographie abdomineller Gefässe an einem 1.0 T-System.

PURPOSE: To evaluate the efficacy of breath-hold, three-dimensional, contrast-enhanced magnetic resonance angiography with a 1.0 T system for imaging the abdominal vessels in comparison to conventional arteriography (CA). METHODS: The abdominal aorta and visceral arteries were studied in 54 patients (60 examinations) on a 1.0 T scanner using an ultrafast gadolinium-enhanced gradient-echo sequence with the following parameters: TR/TE = 3.8/1.4 ms, flip angel 25 degrees, matrix 198 x 256, field 380-420 mm, pixel size 1.9 x 1.48 mm2, slice thickness 1.5-2.5 mm, acquisition time 22-26 sec. Individual circulation times were determined by a test bolus before each MR angiography. Conventional arteriography was performed in 23 of the 60 cases. RESULTS: 172 vessel segments of 23 MR angiographies were compared with CA, sensitivity and specificity were 96.4% and 97.2%. Over-estimations of stenoses or occlusions (n = 4) were caused by the limited resolution of small vessel branches and one stent artifact. CONCLUSION: Contrast-enhanced MR angiography of the abdominal vessels may replace invasive digital subtraction angiography in certain cases like perioperative or peri-interventional diagnostics. Imaging of small peripheral vessels remains a problem and limits use of the method.

[Rational diagnostic imaging of pelvic and acetabulum injuries]. / Rationelle bildgebende Diagnostik von Becken- und Azetabulumverletzungen.

In spite of the widespread availability of CT scanners, conventional X-ray radiographs remain the basic imaging modality in patients with pelvic and/or acetabular trauma. However, the extent of their use will depend on local utilities (e.g., availability of CT scanners) and on the patient's clinical condition. Regarding the inaccuracy of conventional radiography in the diagnosis of injuries of the dorsal pelvic ring and of the acetabulum, computed tomography represents the most important imaging modality in the clinically stable patient. CT provides an exact staging of the extent of trauma and allows for differentiation of pelvic instabilities. CT clearly demonstrates the severity of acetabular trauma and is superior in the detection of local complicating factors, i.e., impressions fractures and (sub-)luxations of the femoral head as well as free intraarticular fragments. CT findings provide the basis for definite treatment regimens of the injured patient. By extension of the examination, all relevant organs and systems (craniospinal, cardiovascular, gastrointestinal, respiratory, genitourinary) can be imaged during one session. The speed of spiral CT scanners and their diagnostic accuracy will play a major role in the management of, especially, polytraumatized patients. The indication for angiography with the option of therapeutic embolization exists if a pelvic bleeding persists even after reposition and operative fixation of the injury.

[The value of MR tomography in acute shoulder dislocations]. / Stellenwert der MR-Tomographie bei akuten Schulterluxationen.

24 patients up to two weeks after primary traumatic shoulder dislocation were examined at 0.5 and 1.5 T. Surgical and/or arthroscopic correlation was available in 13, CT-arthrographic correlation in 16 patients. A joint effusion allowing sufficient evaluation of the capsulolabral complex was present in 21/24 (87.5%) cases. 11/14 patients with combined dislocated detachments of the glenoid labrum and capsular lesions were subsequently operated upon. Marrow edema of the humeral head was found in 16/19 Hill-Sachs lesions and in 4/5 fractures of the greater tuberosity. Two patients presented with a lesion of the long biceps tendon associated with rotator cuff tears and were also subsequently operated upon. MRI performed shortly after primary traumatic shoulder dislocation allows a comprehensive evaluation of the intraarticular lesions and decisively influences further therapy.