Spiral 2D T2-Weighted TSE Brain MR Imaging: Initial Clinical Experience.

BACKGROUND AND PURPOSE: Spiral MR imaging may enable improved image quality and higher scan speeds than Cartesian trajectories. We sought to compare a novel spiral 2D T2-weighted TSE sequence with a conventional Cartesian and an artifact-robust, non-Cartesian sequence named MultiVane for routine clinical brain MR imaging. MATERIALS AND METHODS: Thirty-one patients were scanned with all 3 sequences (Cartesian, 4 minutes 14 seconds; MultiVane, 2 minutes 49 seconds; spiral, 2 minutes 12 seconds) on a standard clinical 1.5T MR scanner. Three readers described the presence and location of abnormalities and lesions and graded images qualitatively in terms of overall image quality, the presence of motion and pulsation artifacts, gray-white matter differentiation, lesion conspicuity, and subjective preference. Image quality was objectivized by measuring the SNR and the coefficients of variation for CSF, GM, and WM. RESULTS: Spiral achieved a scan time reduction of 51.9% and 21.9% compared with Cartesian and MultiVane, respectively. The number and location of lesions were identical among all sequences. As for the qualitative analysis, interreader agreement was high (Krippendorff α > .75). Spiral and MultiVane both outperformed the Cartesian sequence in terms of overall image quality, the presence of motion artifacts, and subjective preference (P < .001). In terms of the presence of pulsation artifacts, gray-white matter differentiation, and lesion conspicuity, all 3 sequences performed similarly well (P > .15). Spiral and MultiVane outperformed the Cartesian sequence in coefficient of variation WM and SNR (P < .01). CONCLUSIONS: Spiral 2D T2WI TSE is feasible for routine structural brain MR imaging and offers high-quality, artifact-robust brain imaging in short scan times.

Effect of image quality and motivation of radiographer teams in mammography after dedicated training and the use of an evaluation tool like PGMI.

INTRODUCTION: High quality and motivated staff are key factors for successful breast imaging teams. The aim of this study is to find out what effects intensive training of already experienced radiographers - including the embedment of evaluation tools and building a new routine workflow - has on image quality and how the motivation and satisfaction of employees change by that. METHODS: A mixed methods study was planned to show changes in image quality simultaneously to motivation of the team after a dedicated training with an expert. Two readers evaluated the quality of 1496 mammograms (775 before, 721 after training) with PGMI (perfect/good/moderate/inadequate) in consensus. To record subjective long-term experiences of the alterations due to the training the radiographers were asked to fill in a written questionnaire. RESULTS: After training the PGMI values considerably shift to a preferred level (p < 0.05) - higher values for P (8,9% to 25,5%) and G (38,2% to 57,1%) and lower values for M (34,1% to 15,4%) and I (18,8% to 1,9%). All radiographers have experienced noticeable improvement and benefit through the initiation of the training. CONCLUSION: After training there is significant improvement in the image quality of mammograms and an increase in motivation and professional well-being of the radiographers. IMPLICATIONS FOR PRACTICE: Due to the urgent need for high quality in breast diagnostics and the worldwide frequency of mammographic examinations, investments should be made to establish thoughtful training programs for radiographers and further develop possibilities for assessment like PGMI.

Diffusion-Weighted Zonal Oblique Multislice-EPI Enhances the Detection of Small Lesions with Diffusion Restriction in the Brain Stem and Hippocampus: A Clinical Report of Selected Cases.

Diffusion restriction is the morphologic hallmark of acute ischemic infarcts and excitotoxic brain injury in various cerebral pathologies. Diffusion restriction is visible as hyperintensity on DWI and as hypointensity on ADC maps. Due to the vicinity of multiple anatomic structures in the brain stem and hippocampus, very small lesions with diffusion restriction may result in severe clinical symptomatology, but these small lesions easily go undetected on standard cerebral DWI due to insufficient spatial resolution, T2* blurring, and image artifacts caused by susceptibility-related image distortions. Diffusion-weighted zonal oblique multislice-EPI with reduced FOV acquisition permits a considerable increase in spatial resolution and enhances the visualization of very small pathologic lesions in the brain stem and hippocampus. Improved performance in the depiction of different pathologic lesions with diffusion restriction in the brain stem and hippocampus using this sequence compared with standard DWI in selected cases is presented.

[Acral necrosis as a complication of urosepsis]. / Akrale Nekrosen als Komplikation einer lithogenen Urosepsis.

Sepsis is the third most common cause of death in Germany. Every fourth patient with sepsis has urosepsis. Even if substantial therapeutic progress has been made, sepsis remains a severe condition with high morbidity and mortality that requires rapid interdisciplinary measures. Besides life-threatening complications, acral necrosis as presented here can occur as a result of disseminated intravascular coagulation and severe microcirculatory disorders.

Displacement of malignant cells into the portal triad of the liver results in reduced liver perfusion, mimicking segmental Fatty liver.

Liver steatosis is often observed in different clinical situations. Oncological patients undergoing systemic therapy often develop liver steatosis, which can be diagnosed with normal routine scans such as CT and ultrasound. In this case report, we show that an isolated infiltration of the portal triad with tumor cells could mimic a fatty-like infiltration of the liver. Radiologists and clinicians should be aware of this pitfall and should perform a biopsy in cases of doubt.

Comparison of standardized pre- and postoperative functional pelvic cine-MRI in patients with a bulbourethral composite suspension due to post-prostatectomy incontinence.

OBJECTIVES: To compare functional pelvic cine-MRI in patients with post-prostatectomy incontinence before and after implantation of a bulbourethral composite suspension. PATIENTS AND METHODS: Functional pelvic 1.5 T cine-MRI was performed at rest, under standardized Valsalva pressure and during micturition in six patients with post-prostatectomy incontinence before and 3 months after a bulbourethral composite suspension. Visibility and positioning of the implant as well as membranous urethral length (MUL) and positioning of the bladder neck (BN) in comparison with the pubococcygeal line (PCL) were evaluated. Clinical outcome was measured by patient-reported pad use and standardized questionnaires (ICIQ-UI SF and I-QOL). Paired data were tested with a Wilcoxon signed-ranks test. RESULTS: Surgery was successfully performed in all patients. All patients returned to complete voiding. The ICIQ-UI SF score decreased significantly from median 16.5 to 5 (p = 0.016). I-QOL increased significantly from 70.5 to 93.5 (p = 0.047). Pad use improved from median 2 pads to 0 pads postoperatively (p = 0.031). Four of six patients were completely pad-free, and 2 were failures with persisting urinary incontinence. MRI revealed significant differences of the MUL at rest with median of 8 mm pre- and 13 mm postoperatively (p = 0.016). BN showed a significant elevation with respect to PCL under Valsalva with in median 0.5 to 5 mm postoperatively (p = 0.016). No significant MRI differences were found between patients showing clinical success or failure. CONCLUSIONS: The bulbourethral composite suspension was associated with an increase in urethral length, urethral coaptation zone and bladder neck elevation, implying a non-compressive mode of action.

Endovascular stent treatment for symptomatic benign iliofemoral venous occlusive disease: long-term results 1987-2009.

Venous stenting has been shown to effectively treat iliofemoral venous obstruction with good short- and mid-term results. The aim of this study was to investigate long-term clinical outcome and stent patency. Twenty patients were treated with venous stenting for benign disease at our institution between 1987 and 2005. Fifteen of 20 patients (15 female, mean age at time of stent implantation 38 years [range 18-66]) returned for a clinical visit, a plain X-ray of the stent, and a Duplex ultrasound. Four patients were lost to follow-up, and one patient died 277 months after stent placement although a good clinical result was documented 267 months after stent placement. Mean follow-up after stent placement was 167.8 months (13.9 years) (range 71 (6 years) to 267 months [22 years]). No patient needed an additional venous intervention after stent implantation. No significant difference between the circumference of the thigh on the stented side (mean 55.1 cm [range 47.0-70.0]) compared with the contralateral thigh (mean 54.9 cm [range 47.0-70.0]) (p=0.684) was seen. There was a nonsignificant trend toward higher flow velocities within the stent (mean 30.8 cm/s [range 10.0-48.0]) and the corresponding vein segment on the contralateral side (mean 25.2 cm/s [range 12.0-47.0]) (p=0.065). Stent integrity was confirmed in 14 of 15 cases. Only one stent showed a fracture, as documented on x-ray, without any impairment of flow. Venous stenting using Wallstents showed excellent long-term clinical outcome and primary patency rate.

Insula-specific responses induced by dental pain. A proton magnetic resonance spectroscopy study.

OBJECTIVES: To evaluate whether induced dental pain leads to quantitative changes in brain metabolites within the left insular cortex after stimulation of the right maxillary canine and to examine whether these metabolic changes and the subjective pain intensity perception correlate. METHODS: Ten male volunteers were included in the pain group and compared with a control group of 10 other healthy volunteers. The pain group received a total of 87-92 electrically induced pain stimuli over 15 min to the right maxillary canine tooth. Contemporaneously, they evaluated the subjective pain intensity of every stimulus using an analogue scale. Neurotransmitter changes within the left insular cortex were evaluated by MR spectroscopy. RESULTS: Significant metabolic changes in glutamine (+55.1%), glutamine/glutamate (+16.4%) and myo-inositol (-9.7%) were documented during pain stimulation. Furthermore, there was a significant negative correlation between the subjective pain intensity perception and the metabolic levels of Glx, Gln, glutamate and N-acetyl aspartate. CONCLUSION: The insular cortex is a metabolically active region in the processing of acute dental pain. Induced dental pain leads to quantitative changes in brain metabolites within the left insular cortex resulting in significant alterations in metabolites. Negative correlation between subjective pain intensity rating and specific metabolites could be observed.

Two cases of cerebral sinus venous thrombosis following chemotherapy for non-seminomatous germ cell tumor.

We report on two patients with cerebral sinus venous thrombosis following chemotherapy with cisplatin, bleomycin and etoposide for non-seminomatous germ cell tumor. Headache and neurological deficits were the leading symptoms. Cancer and cisplatin chemotherapy are well-known risk factors for thromboembolic events. The therapeutic strategy is an anticoagulant therapy. Symptoms are usually reversible within weeks under this therapy. Therefore, in patients with testicular cancer and chemotherapy who present with neurological symptoms, cerebral sinus venous thrombosis should be considered in the differential diagnosis.

Ultrasound-guided antegrade femoral access: comparison between the common femoral artery and the superficial femoral artery.

PURPOSE: The aim of this study was to compare ultrasound-guided access of the superficial femoral artery and the common femoral artery. MATERIAL AND METHODS: 100 patients were randomized to ultrasound-guided access either into the SFA or the CFA. The two groups were compared with respect to technical success, access time and complications. In addition, a subgroup analysis was performed to compare the complication rate using manual compression versus closure devices for haemostasis. RESULTS: In the SFA group 49/50 patients were successfully accessed in the assigned location, compared to 41/50 in the CFA group (p = 0.016). The median access time was significantly faster in the SFA group (3 min 25 s) compared to the CFA group (5 min 26 s) (p < 0.001). The most frequent complications in the SFA group were pseudoaneurysms (16.3%) whereas access site haematomas (14.6%) were the most common complication in the CFA group. However, when looking at subgroup with closure devices there was no difference between the SFA group compared to CFA group (p = 1.000). CONCLUSION: Accessing the SFA was more often successful and significantly faster than puncturing the CFA. The pseudoaneurysm rate was higher in the SFA group when using manual compression, but similar when using closure devices.

Stent implantation for malignant pulmonary artery stenosis in a metastasizing non-small cell bronchial carcinoma.

A 58-year-old patient with recently diagnosed non-small cell bronchial carcinoma was referred to us with increasing shortness of breath and orthopnea by her family practitioner. To exclude the possibility of a pulmonary embolism, contrast medium-enhanced angio-CT of the thorax was performed. This showed a large mediastinal tumor, which, on the one hand, infiltrated and occluded the left upper lobe bronchus and, on the other, constricted the left pulmonary artery over a considerable part of its length. In view of the palliative situation and massively increasing dyspnea, balloon dilatation of the obstructed left pulmonary artery followed by stent placement was performed. This resulted in an immediate improvement of the symptoms. The originally strongly oxygen-dependent and heavily dyspneic patient could be relieved of the external supply of oxygen and was able to sleep normally without additional medication within 24 h. The patient was able ambulate freely within 2 days, with a markedly improved quality of life.

Cervical lymph node metastases of unknown origin: primary tumor detection with whole-body positron emission tomography/computed tomography.

BACKGROUND: Identification of primary tumor in patients with cervical lymph node metastasis of unknown primary (MUO) has a great impact on therapy approach and potentially on patient prognosis. PURPOSE: To assess the diagnostic accuracy of combined positron emission tomography(PET)/computer tomography (CT) for primary tumor detection in cervical metastases of unknown origin compared to PET, CT, and PET+CT side-by-side evaluation. MATERIAL AND METHODS: 39 consecutive patients (eight women, 31 men; mean age 59.9 ± 11.2 years) with MUO were enrolled in this study. PET/CT images were obtained 1 hour after injection of 350 MBq of fluorodeoxyglucose. Oral and intravenous contrast agents were administered in all patients to ensure diagnostic CT data. Fused PET/CT data were evaluated for primary tumor detection. Diagnostic accuracy was calculated and compared with CT alone, PET alone, and side-by-side PET+CT evaluation.Statistical analysis of differences in diagnostic performance between the different imaging procedures was based on the McNemar test. RESULTS: Fused PET/CT depicted the primary tumor in 11 of 39 (28%) patients. In 28(72%) patients, the primary tumor remained occult. CT revealed the primary in five(13%), PET alone in 10 (26%), and side-by-side evaluation of PET+CT in 10 (26%) of 39 patients. Statistical analysis showed no significant differences between the imaging modalities. CONCLUSION: PET, side-by-side PET+CT, and PET/CT revealed similar detection rates for primary tumors in cervical MUO patients. Therefore, cervical metastases of an unknown primary may be assessed with either of these imaging modalities. Detection rates with CT were substantially lower. Thus, inclusion of functional data for assessment of cervical MUO patients must be recommended.

Increased production of vascular endothelial growth factor by peripheral blood mononuclear cells in patients with inflammatory bowel disease.

BACKGROUND: Vascular endothelial growth factor (VEGF) is a potent angiogenic, vascular permeability-enhancing cytokine with overexpression in various pathological disorders, including tumour growth, chronic inflammation and tissue repair. Recent studies have shown significantly increased serum levels of VEGF in patients with inflammatory bowel disease. The origin of the circulating VEGF is still unknown. The present investigation examines the VEGF production by peripheral blood mononuclear cells (PBMCs) in patients with inflammatory bowel disease. METHODS: VEGF levels were measured in culture supernatants of unstimulated PBMCs of 27 patients with inflammatory bowel disease and 10 healthy volunteers using a solid phase ELISA. In addition, VEGF serum levels were determined. RESULTS: PBMCs of both active Crohn's disease patients (1142.6+/-483.9 pg/ml, P < 0.001, n = 12) and active ulcerative colitis patients (748.0+/-637.6 pg/ml, P = 0.006, n = 4) produced significantly higher amounts of VEGF compared with PBMCs of healthy volunteers (113.4+/-101.8 pg/ml, n = 10). In addition, there was a significantly increased VEGF production by PBMCs of patients with active disease compared with PBMCs of patients with quiescent Crohn's disease (261.6+/-254.8 pg/ml, P < 0.001, n = 7) and inactive ulcerative colitis (147.7+/-100.3 pg/ml, P = 0.02, n = 4). There was no significant difference in VEGF release between patients with inactive inflammatory bowel disease and healthy controls. CONCLUSIONS: Significantly increased VEGF production by PBMCs was found in patients with active Crohn's disease and active ulcerative colitis. The study helps to clarify one of the origins of the significantly enhanced VEGF serum levels in patients with active inflammatory bowel disease observed in recent studies.

Best retinal focus for various fication distances in phakic and aphakic eyes.

When an eye focuses on a distant target, it is often found that the long wavelength rays are focused on the receptors, but when the same eye looks at a target close to the eye, the green or blue rays are in focus in the retinal receptors. The authors investigated this phenomenon by means of a laser optometer to find out whether the shift in focus represented an attempt to reduce accommodative effort, or was used to aid distance judgement, or was simply a by-product of the control mechanisms. Six phakic individuals showed a shift of 50 nm over an accommodation range of 2.75 D. The single aphakic observer preferred a retinal focus within a very narrow wavelength range. The authors favor the view that the wavelength shift is an inability of the accommodative control mechanism to make a precise response to a given stimulus.

Insulin secretion in the spiny mouse (Acomys cahirinus). Dose and time kinetic studies with glucose in vivo and in vitro.

Plasma insulin responses to the intravenous injection of glucose in the doses of 0.5, 1.5, and 3.0 gm./kg. were compared in spiny mice (Acomys cahirinus) and weight-matched Swiss albino mice. The mean early (two-minute) plasma insulin response was significantly lower in Acomys at all doses of glucose injected; whereas, at later times (5, 15, and 30 minutes), differences in plasma insulin concentrations in the two species of mice were smaller or nonexistent. Plasma glucose clearance was significantly less in the Acomys. In terms of glucose dose kinetics, there was a decreased capacity of the mean plasma insulin response in Acomys compared with albino mice at two minutes; whereas, at later times, the mean dose response curve for Acomys was shifted to the right of that for albino mice, indicating a decreased sensitivity to glucose in the Acomys. There was, however, a large variation between the plasma insulin responses of the eight individual Acomys mice tested. There was a significant correlation in individual Acomys between the plasma insulin response, expressed as an insulinogenic index, integrated over the thirty minutes after injection of glucose 3.0 gm./kg. in vivo, and the insulin released from pancreatic islets obtained from the corresponding Acomys and perifused for thirty minutes with glucose 1,000 mg./100 ml. in vitro (r = 0.77, p less than 0.05). It is concluded that the rate and magnitude of the insulin response to glucose in an individual Acomys reflects mainly the degree of sensitivity to glucose of the pancreatic beta cells in that animal.

Defective early phase insulin release in perifused isolated pancreatic islets of spiny mice (Acomys cahirinus).

In order to characterize pancreatic beta cell function in Geneva bred spiny mice (acomys cahirinus), the dynamics of immunoreactive insulin release were examined during perifusion of pancreatic islets isolated from normoglycemic acomys. The initial insulin response of acomys was slow: no clear-cut early (1 to 10 min) peak of insulin release was observed when glucose in the perifusion medium was abruptly raised from 2.8 mM to concentrations as high as 56 mM. This was true for islets of either young, or older more obese acomys. However, after 20 to 30 min of perifusion at the high glucose concentrations, the rate of insulin release from acomysislets became similar to that from islets of rats or mice. By contrast, glucose-induced insulin release responses observed with islets of Wistar-derived rats, Swiss albino mice, and inbred C57BL/6J lean or obese (ob/ob) mice, were clearly biphasic. Tolbutamide 1.5 mM, arginine 16 mM, and theophylline 10 mM were ineffective in stimulating insulin release from acomys islets in the presence of a substimulatory glucose concentration (2.8 mM), whereas these agents were effective in rat islets at the same substimulatory concentration of glucose. On the other hand, when these agents, as well as cyclic AMP 10 mM or cytochalasin B 10 mug/ml were applied in the presence of a stimulating concentration of glucose (16.8 mM), the glucose-stimulated insulin release from acomys islets was increased to the same or to a greater extent than from rat islets. It is suggested that the failure of all the agents tested to stimulate an early rapid phase of insulin release from acomys islets may be secondary to the observed initial insensitivity to glucose, which insensitivity may in turn reflect a selective impairment in the recognition of glucose as an insulinogenic signal in this species.