Uni-hemispheric hyperperfusion in the early postictal state: case report.

BACKGROUND: In the emergency setting of acute ischemic stroke, seizures have been reported in up to 4% of patients. In the absence of arterial occlusion, seizures may also cause abnormalities in CT perfusion in 78% of cases when the time window from onset to imaging is short. Both hyperperfusion and hypoperfusion in the postictal state have been described. Also, though rarely reported, postictal perfusion changes can be uni-hemispheric. In these cases, perfusion maps should be analyzed thoroughly, since perfusion reconstruction software relies heavily on a "normal" contralateral perfusion status. CASE PRESENTATION: A 39-year-old man was found on the ground with a minor head injury. On admission, his reactions were generally slow, but there were no other neurological symptoms, and blood pressure was low. The patient had a history of primary generalized epilepsy and admitted to dropping off his anti-epileptic medication. He was transferred to the radiological department for imaging but shortly before began to experience generalized onset tonic-clonic seizures which were brought under control by intravenous therapy with 10 mg diazepam. After approximately 15 min, a multimodal CT scan was performed, revealing marked changes in the perfusion of the brain hemispheres and posterior fossa, with sharp delimitation at the midline. Blood gas analysis was congruent with respiratory acidosis. Clinically, the patient remained awake without developing any new symptoms. He gradually recovered over the following 3 h and, against our medical recommendation, discharged himself from the hospital. CONCLUSIONS: To the authors' knowledge, this is the first report of an early postictal state describing sharply delimited uni-hemispheric hyperperfusion and hemispheric alteration of the cerebellum with an equally split rhombencephalon. Surprisingly, these changes were not associated with any focal neurological signs. To prevent misdiagnosis of perfusion alterations in seizures, radiologists and neurologists should be aware of the limitations of CT perfusion maps and software reconstructions. Novel use of CT perfusion reconstruction using peak enhancement helped in identifying the cerebral pathology.

Rotura traqueal secundaria a intubación selectiva de bronquio derecho / Tracheal rupture hidden by selective intubation of right bronchium

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Biventricular myocardial strain analysis using cardiac magnetic resonance feature tracking (CMR-FT) in patients with distinct types of right ventricular diseases comparing arrhythmogenic right ventricular cardiomyopathy (ARVC), right ventricular outflow-tract tachycardia (RVOT-VT), and Brugada syndrome (BrS).

OBJECTIVES: As underlying heart diseases of right ventricular tachyarrhythmias, ARVC causes wall-motion abnormalities based on fibrofatty myocardial degeneration, while RVOT-VT and BrS are thought to lack phenotypic MR characteristics. To examine whether cardiac magnetic resonance (CMR) feature tracking (FT) in addition to ARVC objectively facilitates detection of myocardial functional impairments in RVOT-VT and BrS. METHODS: Cine MR datasets of four retrospectively enrolled, age-matched study groups [n = 65; 16 ARVC, 26 RVOT-VT, 9 BrS, 14 healthy volunteers (HV)] were independently assessed by two distinctly experienced investigators regarding myocardial function using CMR-FT. Global strain (%) and strainrate (s-1) in radial and longitudinal orientation were assessed at RVOT as well as for left (LV) and right (RV) ventricle at a basal, medial and apical section with the addition of a biventricular circumferential orientation. RESULTS: RV longitudinal and radial basal strain (%) in ARVC (- 12.9 ± 4.2; 11.4 ± 5.1) were significantly impaired compared to RVOT-VT (- 18.0 ± 2.5, p ≤ 0.005; 16.4 ± 5.2, p ≤ 0.05). Synergistically, RVOT endocardial radial strain (%) in ARVC (33.8 ± 22.7) was significantly lower (p ≤ 0.05) than in RVOT-VT (54.3 ± 14.5). For differentiation against BrS, RV basal and medial radial strain values (%) (13.3 ± 6.1; 11.8 ± 2.9) were significantly reduced when compared to HV (21.0 ± 6.9, p ≤ 0.05; 20.1 ± 6.6, p ≤ 0.005), even in case of a normal RV ejection fraction (EF) (> 45%; n = 6) (12.0 ± 2.7 vs. 20.1 ± 6.6, p ≤ 0.05). CONCLUSIONS: CMR-FT facilitates relevant differentiation in patients with right ventricular tachyarrhythmias: between ARVC against RVOT-VT and HV as well as between BrS with even a preserved EF against HV.

[Cystic lesions of the pancreas]. / Zystische Tumoren des Pankreas.

Due to the widespread use of computed tomography (CT) and magnetic resonance imaging (MRI) of the abdomen, the incidence of cystic pancreatic lesions as an incidental finding in asymptomatic patients is increasing; however, most of these lesions are less than 2 cm in size at the time of diagnosis making a correct classification difficult. A more differentiated understanding of the pathophysiology of these lesions has been developed during recent years. Technical improvements in imaging techniques have resulted in an increase in image resolution and has enabled radiologists to differentiate between intraductal papillary mucinous neoplasms (IPMN), serous cystic neoplasms (SCN) and mucinous cystic neoplasms (MCN). A correct classification, including the differentiation from malignant pancreatic tumors, can only be achieved by combining the knowledge of lesion pathophysiology and basic epidemiological data, such as age and sex distribution with modern imaging techniques. In conjunction with the correct diagnosis, the radiologist has to decide on the further management of the newly found lesion. This differs greatly depending on the biological behavior, especially the potential for malignant transformation, e.g. in main duct IPMN. This review gives an overview of the different cystic pancreatic lesions, their underlying pathophysiology and imaging characteristics along with recommendations for the further clinical management.

[Nonocclusive mesenteric ischemia (NOMI): Modern diagnostic and therapeutic interventional strategies from a radiological point of view]. / Nichtokklusive mesenteriale Ischämie (NOMI) : Moderne diagnostische und therapeutisch interventionelle Strategien aus radiologischer Sicht.

BACKGROUND: Nonocclusive mesenteric ischemia (NOMI), a rare form of mesenteric perfusion, is associated with a high mortality rate, especially when the diagnosis is delayed. OBJECTIVE: Optimizing the diagnostic workup and the use of modern diagnostic possibilities are needed to reduce mortality and morbidity. RECOMMENDED APPROACH: Recent studies recommend not yet standardized integration of computed tomography into the diagnostic workup. This paper gives an overview of the current data for the diagnosis of NOMI.

Comparison of manual and semi-automatic measuring techniques in MSCT scans of patients with lymphoma: a multicentre study.

OBJECTIVES: Multicentre evaluation of the precision of semi-automatic 2D/3D measurements in comparison to manual, linear measurements of lymph nodes regarding their inter-observer variability in multi-slice CT (MSCT) of patients with lymphoma. METHODS: MSCT data of 63 patients were interpreted before and after chemotherapy by one/two radiologists in five university hospitals. In 307 lymph nodes, short (SAD)/long (LAD) axis diameter and WHO area were determined manually and semi-automatically. Volume was solely calculated semi-automatically. To determine the precision of the individual parameters, a mean was calculated for every lymph node/parameter. Deviation of the measured parameters from this mean was evaluated separately. Statistical analysis entailed intraclass correlation coefficients (ICC) and Kruskal-Wallis tests. RESULTS: Median relative deviations of semi-automatic parameters were smaller than deviations of manually assessed parameters, e.g. semi-automatic SAD 5.3 vs. manual 6.5 %. Median variations among different study sites were smaller if the measurement was conducted semi-automatically, e. g. manual LAD 5.7/4.2 % vs. semi-automatic 3.4/3.4 %. Semi-automatic volumetry was superior to the other parameters (2.8 %). CONCLUSIONS: Semi-automatic determination of different lymph node parameters is (compared to manually assessed parameters) associated with a slightly greater precision and a marginally lower inter-observer variability. These results are with regard to the increasing mobility of patients among different medical centres and in relation to the quality management of multicentre trials of importance. KEY POINTS: • In a multicentre setting, semi-automatic measurements are more accurate than manual assessments. • Lymph node volumetry outperforms all other semi-automatically and manually performed measurements. • Use of semi-automatic lymph node analyses can reduce the inter-observer variability.

Therapy response evaluation of malignant lymphoma in a multicenter study: comparison of manual and semiautomatic measurements in CT.

PURPOSE: Comparison of manual one-/bi-dimensional measurements versus semi-automatically derived one-/bi-dimensional and volumetric measurements for therapy response evaluation of malignant lymphoma during CT follow-up examinations in a multicenter setting. MATERIALS AND METHODS: MSCT data sets of patients with malignant lymphoma were evaluated before (baseline) and after two cycles of chemotherapy (follow-up) at radiological centers of five university hospitals. The long axis diameter (LAD), the short axis diameter (SAD) and the bi-dimensional WHO of 307 target lymph nodes were measured manually and semi-automatically using dedicated software. Lymph node volumetry was performed semi-automatically only. The therapeutic response was evaluated according to lymphoma-adapted RECIST. RESULTS: Based on a single lymph node, semi-automatically derived multidimensional parameters allowed for significantly more accurate therapy response classification than the manual or the semi-automatic unidimensional parameters. Incorrect classifications were reduced by up to 9.6%. Compared to the manual approach, the influence of the study center on correct therapy classification is significantly less relevant when using semi-automatic measurements. CONCLUSION: Semi-automatic volumetry and bi-dimensional WHO significantly reduce the number of incorrectly classified lymphoma patients by approximately 9.6% in the multicenter setting in comparison to linear parameters. Semi-automatic quantitative software tools may help to significantly reduce wrong classifications that are associated with the manual assessment approach. KEY POINTS: ► Semi-automatic volumetry and bi-dimensional WHO significantly reduce the number of incorrectly classified lymphoma patients ► Manual lymph node evaluation with uni-dimensional parameters is inferior to semi-automatic analysis in a multicenter setting ► Semi-automatic quantitative software tools should be introduced in clinical study evaluation.

[Incidence of prolonged grief disorder in relatives of patients who die during or after admission in Intensive Care Unit]. / Incidencia del trastorno por duelo prolongado en los allegados de pacientes fallecidos durante o tras ingreso en la Unidad de Cuidados Intensivos.

OBJECTIVES: To determine the incidence of «Prolonged Grief Disorder¼ from one year after the death of a relative admitted to the Intensive Care Unit. MATERIAL AND METHODS: A cross-sectional, longitudinal follow-up study was conducted in a general ICU of a reference hospital. The relatives were evaluated approximately one year after the death using the «Consensus Criteria for Prolonged Grief Disorder¼ as a tool. The prevalence between the first and second years was determined. RESULTS: A total of 151 relatives of patients who died in ICU were included. The follow-up was carried out 22.1±5.3 months after the death. Eleven relatives (10.3%) fulfilled the «Consensus Criteria for Prolonged Grief Disorder¼. Of all the grieving relatives, those identified with prolonged grief disorder are the ones who most often require psychological/psychiatric support. CONCLUSIONS: In a sample of close relatives of patients who died in ICU, a significant minority fulfilled the criteria for «Prolonged Grief Disorder¼ 1-2 years after the death. This condition, which is often overlooked, and could require some kind of psychological treatment, should be taken into consideration.

Relación entre el gradiente alveolo-arterial de oxígeno y la PaO2/FiO2 introduciendo la PEEP en el modelo / Relationship between the alveolar-arterial oxygen gradientand PaO2/FiO2-introducing peep into the model

Objetivo: Valorar si el gradiente alveolo-arterial de oxígeno (Grad[A-a]O2) ayuda a confirmar la influencia de la PEEP en la PaFi (PaO2/FiO2). Diseño: Estudio observacional; usamos una regresión lineal para realizar un estudio multivariable y mejorar la fórmula de la PaFi teniendo en cuenta la PEEP. Ámbito: Hospital terciario. Pacientes: Todos los pacientes de cuidados intensivos, con o sin daño pulmonar. Variables de interés principal: Registramos los antecedentes personales, juicio clínico, datos durante ingreso en UCI, puntuaciones de severidad en el primer día y durante evolución; dos variables calculadas: PaFi and Grad(A-a)O2. Resultados: Un total de 956 patientes incluidos; 63,9% hombres; edad mediana 68 años. Primer día, 31,8% no tienen ventilación mecánica (VM), 13,1% tienen VM no invasiva y 55,1% VM invasiva. PaFi: 32,9% 0-200, 32,2% 201-300, y 34,8% >300. PEEP: 0-5 69,8%, 6-10 27,5% y >10 2,6%. Observamos una correlación (Pearson) entre el Grad(A-a)O2 y la PaFi de -0,84 (p<0,001). Realizamos una regresión múltiple (variable dependiente: Grad(A-a)O2Grad[A-a]O2); variables incluidas en el modelo: PaFi, PEEP, APACHE IV y SOFA; coeficiente de determinación (R2) de 0,62 sin PEEP y 0,72 con PEEP. Cambiamos la fórmula de la PaFi, denominándola PaFip (PaFi más PEEP): Ln (PaFi/[PEEP+12]). El índice de correlación entre PaFip y Grad(A-a)O2: -0,9 (p<0,001). Realizamos una regresión lineal (variable dependiente: Grad[A-a]O2) y utilizamos PaFip en vez de la PaFi. Solo la PaFi permanece en el modelo, y es discretamente complementada por APACHE IV; R2 0,8. Conclusiones: Añadiendo la PEEP a la PaFi, creamos una variable (PaFip) que mejora el modelo, demostrando mayor capacidad de bondad de ajuste (AU)

Objectives To determine whether the alveolar-arterial oxygen gradient (Grad[A-a]O2) helps confirm the influence of PEEP on PaFi (PaO2/FiO2). Design: Observational study; we used linear regression to perform a multivariate study to improve the PaFi formula by taking PEEP into account. Setting: Tertiary hospital. Patients: We included all patients who were admitted to the intensive care unit, regardless of pulmonary damage. Variables: We recorded personal history, clinical judgment, intensive care data, severity scores on the first day and progression. Two calculated variables: PaFi and Grad(A-a)O2. Results: A total of 956 patients were included: 63.9% men; median age 68 years. On the first day, 31.8% did not have mechanical ventilation (MV), 13.1% had non-invasive MV and 55.1% had invasive MV. PaFi values: 32.9% 0-200, 32.2% 201-300, and 34.8% >300. PEEP values: 0-5 69.8%, 6-10 27.5% and >10 2.6%. We observed a correlation (Pearson) between Grad(A-a)O2 and PaFi of -0.84 (p<0.001). On performing multiple regression (dependent variable: Grad[A-a]O2), the following variables were included in the model: PaFi, PEEP, APACHE IV and SOFA; coefficient of determination (R2) of 0.62 without PEEP and 0.72 with PEEP. We changed the PaFi formula, referring to it as PaFip (PaFi plus PEEP): Ln (PaFi/[PEEP+12]). Correlation index between PaFip and Grad(A-a)O2: -0.9 (p<0.001). We performed linear regression (dependent variable: Grad[A-a]O2) and used PaFip instead of PaFi. Only PaFi remained in the model, and was discretely complemented by APACHE IV; R2=0.8. Conclusions: By adding PEEP to the PaFi model (PaFip), we clearly improve the latter, as reflected by a better goodness of fit (AU)

[Severe thrombocytopenia on admission to the intensive care unit in patients with multiple organ failure]. / Trombocitopenia grave al ingreso en una unidad de cuidados intensivos en pacientes con disfunción multiorgánica.

OBJECTIVE: To evaluate the frequency of severe thrombocytopenia (STCP) (≤ 50,000/µl) in the first 24 hours in patients with multiple organ dysfunction syndrome, and the factors that influence its occurrence. DESIGN: A retrospective, observational study. AREA: Medical-surgical intensive care unit (ICU). Tertiary hospital. PATIENTS: Those with failure of at least two organs, according to SOFA criteria, with the exclusion of neurological and traumatologic critical cases. VARIABLES: Medical history, regular medication, baseline functional status, demographic variables, severity scores in ICU, multiple-organ failure data, course in ICU and main hospital data. RESULTS: A total of 587 patients were included; 6.3% (37 patients) presented with STCP during the first day of admission; 64.6% were men; SOFA 8 (5-10); APACHE II 18 (13-24); APACHE IV 59 (46-73); 32.5% were surgical patients. A total of 79.9% subsequently needed mechanical ventilation, and 71.4% required vasoactive drugs. Overall stay in ICU: 4 (2-10) days, main hospital stay 18 (9-35) days. A total of 29.2% died in the ICU; 11.7% developed STCP during admission to the ICU. Multivariate analysis found the main determining factors in the occurrence of thrombocytopenia on admission to be: history of hospitalization in the last year, albumin and bilirubin levels, and sepsis. CONCLUSION: The prevalence of STCP among critical patients was 6.3%. Its occurrence was associated with albumin and bilirubin levels, sepsis, and with patient admittance in the last year.

[Relationship between the alveolar-arterial oxygen gradient and PaO2/FiO2-introducing PEEP into the model]. / Relación entre el gradiente alveolo-arterial de oxígeno y la PaO2/FiO2 introduciendo la PEEP en el modelo.

OBJECTIVES: To determine whether the alveolar-arterial oxygen gradient (Grad[A-a]O2) helps confirm the influence of PEEP on PaFi (PaO2/FiO2). DESIGN: Observational study; we used linear regression to perform a multivariate study to improve the PaFi formula by taking PEEP into account. SETTING: Tertiary hospital. PATIENTS: We included all patients who were admitted to the intensive care unit, regardless of pulmonary damage. VARIABLES: We recorded personal history, clinical judgment, intensive care data, severity scores on the first day and progression. Two calculated variables: PaFi and Grad(A-a)O2. RESULTS: A total of 956 patients were included: 63.9% men; median age 68 years. On the first day, 31.8% did not have mechanical ventilation (MV), 13.1% had non-invasive MV and 55.1% had invasive MV. PaFi values: 32.9% 0-200, 32.2% 201-300, and 34.8% >300. PEEP values: 0-5 69.8%, 6-10 27.5% and >10 2.6%. We observed a correlation (Pearson) between Grad(A-a)O2 and PaFi of -0.84 (p<0.001). On performing multiple regression (dependent variable: Grad[A-a]O2), the following variables were included in the model: PaFi, PEEP, APACHE IV and SOFA; coefficient of determination (R²) of 0.62 without PEEP and 0.72 with PEEP. We changed the PaFi formula, referring to it as PaFip (PaFi plus PEEP): Ln (PaFi/[PEEP+12]). Correlation index between PaFip and Grad(A-a)O2: -0.9 (p<0.001). We performed linear regression (dependent variable: Grad[A-a]O2) and used PaFip instead of PaFi. Only PaFi remained in the model, and was discretely complemented by APACHE IV; R²=0.8. CONCLUSIONS: By adding PEEP to the PaFi model (PaFip), we clearly improve the latter, as reflected by a better goodness of fit.

[Thoracic radiology in the intensive care unit]. / Thoraxradiologie auf der Intensivstation.

The clinical evaluation of the intensive care unit patient is based upon multiple parameters, including portable chest x-ray examination. Knowledge of the methods, capabilities, and limitations is prerequisite for a legally correct and medically reasonable approach. This report provides basic knowledge about pleural und pulmonary pathologies, e.g., pneumothorax, pleural effusion, atelectasis, aspiration, pneumonia, lung edema, and acute respiratory distress syndrome.

[Migration of a retained intra-abdominal foreign body into the colon]. / Migration eines intraoperativ belassenen Bauchtuches in das Kolon.

Even in the era of correct precautions and risk management culture adverse and preventable adverse events, such as intraoperatively residual foreign bodies remain a hot topic. Due to legal considerations and possible image loss many cases may remain unpublished leading to an underestimation of the real incidence in literature. The following casuistic is an example for a rarely documented and in this case a partial migration of a retained surgical sponge into the colon. The causes for the delayed foreign body detection, accounting for the relative good health even during chemoradiotherapy are analyzed in order to sharpen the awareness of such serious complications.