An atypical lateral hernia and concomitant inguinal and umbilical hernias in a patient with polycystic kidney disease and an intracranial aneurysm - a combined approach of clinical and radiological investigation, endoscopic hernia repair, and anatomical cadaver model documentation and a systematic review of the literature.

Atypical hernias are difficult to diagnose due to their rarity and often unspecific symptoms. In the literature there exist hints to peri-inguinal hernias, i.e. direct lateral hernia, but most of them are forms of Spigelian hernias. Since the majority were described during the first half of the past century or even earlier, only very few cases have been documented using modern diagnostic techniques. We report a unique case of a 51 year old patient presenting with an atypical inguinal hernia with concomitant inguinal and umbilical hernias in combination with cystic kidney disease and intracranial aneurysm. The atypical position of the hernia was assumed from clinical inspection, ultrasound and CT scan and verified during pre-peritoneoscopy. Using an anatomical cadaver dissection approach, we followed the unusual position of the hernia through the abdominal wall below the aponeurosis of the external oblique muscle. After a thorough literature search, we assume that the present hernia containing a hernial sac has not been documented before, especially not in such a multidisciplinary approach comprising radiological, surgical and anatomical localisation and endoscopic treatment in a patient with a clinical situation being aggravated by large cystic kidneys leading to dialysis-dependency. Rare hernias have been described as being often associated with concomitant inguinal or other hernias, a predisposition for the male gender and a pathogenic mechanism related to other soft tissue defects such as cystic kidney disease or cranial aneurysm. Thus, we consider this a unique case that has not been documented in this constellation previously, which may increase the awareness for these rare hernias.

Radiation dose values for various coronary calcium scoring protocols in dual-source CT.

PURPOSE: The purpose of this study was to assess the radiation dose and associated image noise of previously suggested calcium scoring protocols using dual-source CT. METHODS: One hundred consecutive patients underwent coronary calcium scoring using dual-source CT. Patients were randomly assigned to five different protocols: retrospective ECG-gating and tube current reduction to 4% outside the pulsing window at 120 (protocol A) and 100 kV (B), prospective ECG-triggering at 120 (C) and 100 kV (D), and prospective ECG-triggering at 100 kV with attenuation-based tube current modulation (E). Radiation dose parameters and image noise were determined and compared. RESULTS: Protocol A resulted in an effective dose of 1.3 +/- 0.2 mSv, protocol B in 0.8 +/- 0.2 mSv, protocol C in 1.0 +/- 0.2 mSv, protocol D in 0.6 +/- 0.1 mSv, and protocol E in 0.7 +/- 0.1 mSv. Effective doses were significantly lower (P < 0.001) with 100 kV when compared to 120 kV protocols, and were significantly lower (P < 0.001) for prospective versus retrospective ECG-gating. No significant difference was found between protocol D and E. Significant negative correlations were found between the CTDI(vol) and heart rate for both retrospective ECG-gating protocols (protocol A: r = -0.98, P < 0.001; protocol B: r = -0.83, P < 0.001). The mean image noise was 29.0 +/- 6.7 HU, with no significant differences between the five protocols. The image noise was significantly correlated with the body weight (r = 0.21, P < 0.05) and BMI (r = 0.31, P < 0.01). CONCLUSIONS: Effective dose of calcium scoring using dual-source CT ranges from 0.6 to 1.3 mSv. Prospective triggering and lower tube voltage significantly reduces the radiation but yield similar image noise.