[Dispensing with sedation in pediatric MR imaging of the brain: what is feasible?]. / Verzicht auf Sedierungen bei pädiatrischen MRT-Untersuchungen des Kopfes: Was ist machbar?

PURPOSE: Feasibility study to evaluate whether a diagnostic pediatric MRI scan of the brain can be performed without sedation by using BLADE sequences with rotating blade-like k-space covering. MATERIALS AND METHODS: Between 01/09 and 12/10 all children with a planned MRI of the brain were included. After age-dependent preparation of the child the MRI was acquired with a parent closely attending. Pharmacological sedation was only applied when strong motion artifacts occurred. All MRI sequences were independently reviewed by 2 radiologists who ranked image quality on a scale of III (excellent image quality, no motion artefacts), II (motion artefacts but still diagnostic quality), and I (non-diagnostic image quality). RESULTS: 326 children (53 % male, mean age 7.2 ± 4.3 years) were evaluated of whom 247 (76 %) had to be sedated. All infants < 1 year and 84 % of 1-year-old patients, 90 % of 2-year-old, 59 % of 3-year-old, 9 % of 4-year-old children, and 2 % of patients older than 4 years had to be sedated. In total, 2461 MRI sequences (7.6 ± 1.2 per study) including 622 BLADE sequences (25 %) were acquired. Reviewer A rated 2077 sequences (84 %) as III, 318 (13 %) as II, and 66 (3 %) as I, whereas reviewer B rated 2119 sequences (86 %) as III, 308 (13 %) as II, and 34 (1 %) as I. Inter-observer agreement was good to excellent (normal/weighted kappa value for BLADE sequences: 0.88/0.56, for all sequences: 0.92/0.71). CONCLUSION: Age-adjusted preparation and implementation of a pediatric cranial MRI may reduce the need for sedation. BLADE sequences abate motion artefacts thus enabling acquisition of diagnostic images even in young children. In patients older than 3 years, performance of MRI scans without sedation should be considered.

[Analysis of image acquisition, post-processing and documentation in adolescents with spine injuries - comparison before and after referral to a university hospital]. / Bildgebung bei wirbelsäulenverletzten Kindern und jungen Erwachsenen - eine Analyse von Umfeld, Standards und Wiederholungsuntersuchungen bei Patientenverlegungen.

PURPOSE: Systematic evaluation of imaging situation and standards in acute spinal injuries of adolescents. MATERIALS AND METHODS: Retrospective analysis of imaging studies of transferred adolescents with spinal injuries and survey of transferring hospitals (TH) with respect to the availability of modalities and radiological expertise and post-processing and documentation of CT studies were performed. Repetitions of imaging studies and cumulative effective dose (CED) were noted. RESULTS: 33 of 43 patients (77 %) treated in our hospital (MA 17.2 years, 52 % male) and 25 of 32 TH (78 %) were evaluated. 24-hr availability of conventional radiography and CT was present in 96 % and 92 % of TH, whereas MRI was available in only 36 %. In 64 % of TH, imaging expertise was guaranteed by an on-staff radiologist. During off-hours radiological service was provided on an on-call basis in 56 % of TH. Neuroradiologic and pediatric radiology expertise was not available in 44 % and 60 % of TH, respectively. CT imaging including post-processing and documentation matched our standards in 36 % and 32 % of cases. The repetition rate of CT studies was 39 % (CED 116.08 mSv). CONCLUSION: With frequent CT repetitions, two-thirds of re-examined patients revealed a different clinical estimation of trauma severity and insufficient CT quality as possible causes for re-examination. A standardization of initial clinical evaluation and CT imaging could possibly reduce the need for repeat examinations.

[Prognostic pulmonary and thoracic findings in patients with unstable injuries of the thoracic spine]. / Prognostische pulmonale und thorakale Befunde bei Patienten mit instabilen Verletzungen der Brustwirbelsäule.

BACKGROUND: Instable fractures of the thoracic spine imply a substantial trauma to the chest. The aim of this study was to undertake a systematic analysis of the prognostic impact of CT findings of the chest wall, mediastinum, lungs, and pleural space on the mortality rate. METHOD: All multiple injury patients with instable fractures of the thoracic spine and initial CT scans treated in our clinic from April 2004 to May 2007 were eligible. The following variables were evaluated for their prognostic power: injury to the lungs (pneumothorax, effusion, lung contusions/lacerations, atelectasis), mediastinum (vessel dissection/rupture, bleeding, diaphragmatic rupture), chest wall (bruises, soft tissue emphysema, rib fractures), and need for pre-diagnostic tube thoracostomy. The significance level was set to P = 0.05. PATIENTS: Of a total of 33 patients (mean age: 43.5 ± 20.1 years [range 14 - 83 years]; 25-male [76 %]), seven patients (21 %) died with women being significantly more affected (P < 0.001). Mortality rate was not influenced by patient age. RESULTS: Non-survivors displayed significantly higher median lung contusion score values compared to survivors (4.0 [0 - 12] versus 1.0 [0 - 10]; P = 0.016). The following variables revealed a significant association with the mortality rate: chest wall bruises with soft tissue emphysema > 90 ° of the thoracic circumference (sensitivity [SE]: 43 %, specificity [SP]: 100 %, positive predictive value [PPV]: 100 %, negative predictive value [NPV]: 87 %, overall accuracy [OA]: 88 %; P = 0.006), rib fractures (SE: 71 %, SP: 81 %, PPW: 50 %, NPW: 91 %, OA: 79 %; P = 0.016), mediastinal haematoma (SE: 71 %, SP: 77 %, PPW: 45 %, NPW: 91 %, OA: 76 %; P = 0.027), and bilateral pneumothoraces (SE: 29 %, SP: 100 %, PPW: 100 %, NPW: 84 %, OA: 85 %; P = 0.040). CONCLUSION: Multiply injured patients with instable fractures of the thoracic spine display CT findings indicative of non-survival. Image acquisition and interpretation focusing solely on the spine should be avoided to ensure the detection of prognostic injury patterns to the lungs.

[Mediastinal metastasis of a tubal choriocarcinoma following ectopic pregnancy as a rare cause of thoracic pain]. / Mediastinale Metastase eines tubaren Chorionkarzinoms nach ektoper Schwangerschaft als seltene Ursache thorakaler Schmerzen.

We report on a 26-year old female patient with thoracic pain and dyspnea, in whom a large tumorous mass in the anterior mediastinum with a pleural effusion was diagnosed by computed tomography and magnetic resonance imaging. After rapid progression of tumor growth and detection of malignant cells within the pleural effusion operative intervention including resection of the tumor was performed. Histologic examination of the tumor revealed the typical morphology of a large mediastinal choriocarcinoma. The excessively high hCG-levels returned to normal values post-operatively. A thorough history making revealed an ectopic pregnancy which had made unilateral salpingectomy necessary. Although primary histologic examination of the tubarian tissue had shown no malignancy, a secondary look revealed a choriocarcinoma with identical histological features compared to the mediastinal tumor. Thus, final diagnosis of a mediastinal metastasis of a tubarian choriocarcinoma in ectopic pregnancy was made. We discuss this extremely rare disease and provide a short overview of the literature.

[Non-passable tumor-associated stenosis of trachea and stent-implantation -- an indication for Virtual CT-bronchoscopy]. / Stent-Implantationsplanung bei tumor-assoziierter, brochoskopisch nicht passierbarer Trachealstenose -- Eine Indikation für die virtuelle CT-Bronchoskopie.

We report about a male 50-year-old patient with known non-small cell lung cancer and tumor-associated stenosis of the right main bronchus already treated with Neodym-YAG-laser coagulation. Eight months later the patient was readmitted to hospital and revealed complete occlusion of the right main bronchus and subtotal stenosis of the distal trachea and the left main bronchus. Conventional tracheobronchoscopy failed to visualize the post-stenotic parts of the left main bronchus due to the length and degree of stenosis. Multidetector-CT-generated virtual tracheobronchoscopy was able to demonstrate complete intraluminal tumor extent thus making precise pre-interventional measurements for stent implantation possible. Furthermore, post-interventional re-evaluation by virtual tracheobronchoscopy confirmed correct position and patency of the stent located within the distal trachea and the left main bronchus. Our case report demonstrates a non-invasive and easy approach for evaluating the tracheobronchial system in a patient with tumor-associated airway stenosis including the possibility for viewing beyond post-stenotic segments.

[Prospective randomized trial of a modified standard multislice CT protocol for the evaluation of multiple trauma patients]. / Prospektive, randomisierte Evaluation eines modifizierten Mehrdetektor-CT-Protokolls in der Initialdiagnostik beim Polytrauma.

PURPOSE: To evaluate whether modification of a standard multislice CT (MSCT) protocol might improve the diagnostic work flow in patients with multiple trauma without relevant loss of image quality. MATERIALS AND METHODS: Between September 2002 and September 2003, 80 multiple trauma patients underwent 4-slice CT encompassing head, thorax, abdomen/pelvis and spine. All patients were randomly assigned to either protocol A or B: Protocol A included serial scanning of the head (collimation 1 mm, 350/380 mAs/120 kV) and spiral scans of thorax, abdomen/pelvis and spine (collimation 2.5 mm, 220 mAs/120 kV) with gantry angulation and arm elevation; protocol B included spiral scanning of all body regions (collimation 2.5 mm, 300/150 mAs/120 kV) without gantry angulation or arm elevation. Time intervals, radiation exposure and results of the initial and final analysis were documented. RESULTS: In the investigated 64 male and 16 female patients (mean age 41.7 years), 88.7 % of the 407 pathologic findings were correctly identified on the initial images. Protocol B revealed a significant decrease in scan time (6.4 vs. 16.8 min., p < 0.001), time in the CT examination room (22.9 vs. 32.8 min.; p < 0.001), time until initial (25.3 vs. 35.8 min.; p < 0.001) and final image analysis (93.7 vs. 112.9 min; p < 0.005). No significant difference was found for patient transport time and image reconstruction time. Protocol B has a significantly lower effective radiation dose compared to protocol A (10.2 vs. 12.7 mSv, p < 0.001). CONCLUSIONS: Applying a modified MSCT protocol without gantry angulation and arm elevation can significantly decrease radiation exposure and examination time in multiple trauma patients without relevant loss of diagnostic image information and, consequently, has the potential of improving the diagnostic process and prognosis in multiple trauma patients.

[Misdiagnosis of a Leiomyosarcoma of the inferior vena cava as a renal cell carcinoma]. / Fehldeutung eines Leiomyosarkoms der V. cava inferior als Nierenzellkarzinom.

Leiomyosarcoma of the vena cava inferior (VCI) is a rare mesenchymal malignant tumor of the retroperitoneum. About 200 cases have been described in the literature so far. Leiomyosarcomas may resemble other tumors including renal cell carcinoma, adrenal carcinoma, and hepatic adenoma. Thus, misinterpretation of a leiomyosarcoma of the VCI is a common problem. We present a 71-year-old female with a large subhepatic, retroperitoneal tumorous mass which was diagnosed to be a renal cell carcinoma by sonography and computed tomography. After application of magnetic resonance imaging and retrospective analysis of the CT scan, diagnosis could be revised. Laparotomy and en bloc resection of the tumor was performed; histopathological examination confirmed a leiomyosarcoma of the VCI. The postoperative course was unremarkable. Leiomyosarcoma of the VCI may resemble advanced stages of renal cell carcinoma. High-resolution imaging modalities (computed tomography, magnetic resonance imaging) are able to precisely evaluate the typical imaging characteristics of leiomyosarcomas, thus determining correct diagnosis in affected patients. This is essential for successful operative therapy.