Systematic evaluation of imaging techniques and baseline characteristics in patients with suspected vasculitis.

Purpose: To assess the diagnostic value of different imaging modalities in distinguishing systemic vasculitis from other internal and immunological diseases. Methods: This retrospective study included 134 patients with suspected vasculitis who underwent ultrasound, magnetic resonance imaging (MRI), or 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) between 01/2010 and 01/2019, finally consisting of 70 individuals with vasculitis. The main study parameter was the confirmation of the diagnosis using one of the three different imaging modalities, with the adjudicated clinical and histopathological diagnosis as the gold standard. A secondary parameter was the morphological appearance of the vessel affected by vasculitis. Results: Patients with systemic vasculitis had myriad clinical manifestations with joint pain as the most common symptom. We found significant correlations between different imaging findings suggestive of vasculitis and the final adjudicated clinical diagnosis. In this context, on MRI, vessel wall thickening, edema, and diameter differed significantly between vasculitis and non-vasculitis groups (p < 0.05). Ultrasound revealed different findings that may serve as red flags in identifying patients with vasculitis, such as vascular occlusion or halo sign (p = 0.02 vs. non-vasculitis group). Interestingly, comparing maximal standardized uptake values from PET/CT examinations with vessel wall thickening or vessel diameter did not result in significant differences (p > 0.05). Conclusions: We observed significant correlations between different imaging findings suggestive of vasculitis on ultrasound or MRI and the final adjudicated diagnosis. While ultrasound and MRI were considered suitable imaging methods for detecting and discriminating typical vascular changes, 18F-FDG PET/CT requires careful timing and patient selection given its moderate diagnostic accuracy.

Comprehensive comparison of three different workstations for accurate planning of endovascular stent implantation in patients with thoracic aortic aneurysms.

Purpose: To assess the diagnostic precision of three different workstations for measuring thoracic aortic aneurysms (TAAs) in vivo and ex vivo using either pre-interventional computed tomography angiography scans (CTA) or a specifically designed phantom model. Methods: This retrospective study included 23 patients with confirmed TAA on routinely performed CTAs. In addition to phantom tube diameters, one experienced blinded radiologist evaluated the dimensions of TAAs on three different workstations in two separate rounds. Precision was assessed by calculating measurement errors. In addition, correlation analysis was performed using Pearson correlation. Results: Measurements acquired at the Siemens workstation deviated by 3.54% (range, 2.78-4.03%; p = 0.14) from the true size, those at General Electric by 4.05% (range, 1.46-7.09%; p < 0.0001), and at TeraRecon by 4.86% (range, 3.22-6.45%; p < 0.0001). Accordingly, Siemens provided the most precise workstation at simultaneously most fluctuating values (scattering of 4.46%). TeraRecon had the smallest fluctuation (scattering of 2.83%), but the largest deviation from the true size of the phantom. The workstation from General Electric showed a scattering of 2.94%. The highest overall correlation between the 1st and 2nd rounds was observed with measurements from Siemens (r = 0.898), followed by TeraRecon (r = 0.799), and General Electric (r = 0.703). Repetition of measurements reduced processing times by 40% when using General Electric, by 20% with Siemens, and by 18% with TeraRecon. Conclusions: In conclusion, all three workstations facilitated precise assessment of dimensions in the majority of cases at simultaneously high reproducibility, ensuring accurate pre-interventional planning of thoracic endovascular aortic repair.

Quiescent-Interval Slice Selective Magnetic Resonance Angiography for Abdominal Aortic Aneurysm Treatment Planning.

PURPOSE: Diagnostic imaging of Abdominal aortic aneurysm (AAA) almost exclusively employs CT angiography (CTA) involving X-ray exposure and contrast medium that may harm some patients. Quiescent-Interval Slice Selective MR (QISS-MR) depicts vascular anatomy without radiation or contrast medium. The diagnostic quality of QISS-MRA and CTA were compared in regard to length and diameter measurements in AAA patients. Suitability of QISS-MRA for AAA treatment planning was evaluated. MATERIALS AND METHODS: The details of 30 patients with AAA who received both a QISS-MR and CTA for a known infrarenal AAA were obtained retrospectively that was approved by the local research ethics board. Two observers analyzed each dataset in terms of image quality and determined lumen diameter and length of 15 vessel segments. RESULTS: Highly accurate agreement between the diagnostic scores from the two observers was achieved. There was no significant difference between CTA and QISS-MRA for all 15 measured vessels. Although information on calcification was lacking and intraluminal thrombus was visualized in only 25 patients out of 30 patients, a founded decision to carry out OR or EVAR was possible with both imaging modalities. CONCLUSION: QISS-MRA presents a radiation and contrast free method for preoperative diagnostic AAA imaging. While QISS-MRA does not deliver exact information regarding calcification and thrombus formation, it does accurately allow measurement of vessel diameter and length. Therefore, it is potentially useful for EVAR planning in selected patients with impaired renal function.

[Therapy of Peripheral Artery Aneurysms]. / Therapie primärer Aneurysmen der Extremitätenarterien.

Peripheral arterial aneurysms are rare vascular pathologies characterised by focal dilatation of at least 1.5-fold relative to the diameter of the native vessel. Primary arterial aneurysms can affect any segment of the arterial trunk. Diagnostic tests include duplex sonography, CT and MR angiography, and digital subtraction angiography. It is essential that the influx and efflux to the aneurysm should be mapped as precisely as possible. The most common type of peripheral arterial aneurysms are popliteal artery aneurysms, which frequently occur with aorta aneurysms. Peripheral arterial aneurysms are more common in patients with connective tissue disease or autoimmune disease (Ehlers-Danlos syndrome, Marfan syndrome, Behçet's disease). The current gold standard for therapy is surgery, although endovascular therapies have also been described. As the condition is rare, there is insufficient evidence to compare these approaches. Results from several register studies and single centre studies in patients with popliteal aneurysms indicate that endovascular therapy can give similar outcomes to open therapy if patients are carefully selected. Nevertheless, open surgery remains the gold standard. Therapy of aneurysms of the extremities must consider individual treatment criteria, such as the morphology of the aneurysm, its anatomical localisation - particularly with respect to mobilise segments, vascular efflux and the patient's general condition.

Dynamic 4D-CT Angiography for Guiding Transarterial Chemoembolization: Impact on the Reduction of Contrast Material, Operator Radiation Exposure, Catheter Consumption, and Diagnostic Confidence.

PURPOSE: This study was carried out to investigate the impact of abdominal dynamic four-dimensional CT angiography (4D-CTA) for guiding transarterial chemoembolization (TACE) on the amount of contrast material used, operator radiation exposure, catheter consumption, and diagnostic confidence. MATERIALS AND METHODS: Written consent was waived for this IRB-approved retrospective study. 29 patients (20 men; mean age: 65.7 ±â€Š11.5 years) with malignant liver lesions underwent 4D-CTA, prior to initial TACE. Time-resolved volume-rendering technique (VRT), maximum-intensity projection (MIP), and multiplanar reconstruction (MPR) series were reconstructed, enabling a direct selective catheterization of the tumor-supplying artery without prior conventional digital subtraction angiography (DSA). 29 patients (16 men; mean age: 69.4 ±â€Š13.9) who underwent traditional TACE served as the control group. The amount of administered contrast media, operator radiation exposure, and catheter consumption during TACE were compared. Two radiologists assessed diagnostic confidence in the exclusion of portal vein thrombosis. RESULTS: 4D-CTA TACE resulted in a significant reduction in the amount of contrast media used, compared to traditional TACE (-61.0 ml/ -66.3 % intra-arterial, -12.8 ml/ -13.8 % overall; P < 0.001). The dose-area product indicating operator radiation exposure during intervention was reduced by 50.5 % (P < 0.001), and 0.7 fewer catheters on average were used (P = 0.063), while 4D-CTA data was available to guide TACE. Diagnostic confidence in the exclusion of portal vein thrombosis was significantly enhanced by 4D-CTA, compared to traditional DSA images (scores, 3.9 and 2.4, respectively; P < 0.001). CONCLUSION: Dynamic 4D-CTA enables TACE with a substantially reduced amount of contrast material, decreases operator radiation exposure, and increases diagnostic confidence in the exclusion of portal vein thrombosis. KEY POINTS: · 4D-CTA prior to TACE decreases the amount of utilized contrast material.. · The intra-arterial fraction of contrast media can be reduced by two-thirds.. · The risk of CIN may be decreased by means of 4D-CTA TACE.. · Operator radiation exposure is lower using 4D-CTA for guiding TACE.. · 4D-CTA portography allows for a higher diagnostic confidence than conventional DSA images.. CITATION FORMAT: · Albrecht MH, Vogl TJ, Wichmann JL et al. Dynamic 4D-CT Angiography for Guiding Transarterial Chemoembolization: Impact on the Reduction of Contrast Material, Operator Radiation Exposure, Catheter Consumption, and Diagnostic Confidence. Fortschr Röntgenstr 2018; 190: 513 - 520.

Assessment of the cochlear nerve to facial nerve size ratio using MR multiplanar reconstruction of the internal auditory canal in patients presenting with acquired long-standing hearing loss.

OBJECTIVE: To test using the facial nerve as a reference for assessment of the cochlear nerve size in patients with acquired long-standing sensorineural hearing loss (SNHL) using MRI multiplanar reconstruction. METHODS: The study was retrospectively performed on 86 patients. Group 1 (study group, n = 53) with bilateral long-standing SNHL. Group 2 (control group, n = 33) without hearing loss. The nerve size was measured by drawing a region of interest around the cross-sectional circumference of the nerve in multiplanar reconstruction images. RESULTS: No significant correlation was noted between the cochlear nerve and facial nerve size, and the patient's age, gender and weight (p > 0.05). In Group 1, the mean ratio of the cochlear to facial nerve size was 0.99 ± 0.30 (range: 0.52-1.86) and 1.12 ± 0.35 (range: 0.34-2.3) for the right and left sides, respectively. In Group 2, it was 1.18 ± 0.23 (range: 0.78-1.71) and 1.25 ± 0.25 (range: 0.85-1.94) for the right and left sides, respectively. The cochlear nerve size was statistically (p = 0.0004) smaller in Group 1 than in Group 2. CONCLUSION: The cochlear nerve size and the cochlear to facial nerve size ratio are significantly smaller in patients with acquired long-standing SNHL. Advances in knowledge: The facial nerve can be used as a reference for assessment of the cochlear nerve in patients with acquired long-standing SNHL.

Thrombosis of the Inferior Vena Cava after Endovascular Aortic Repair in a Patient with May-Thurner Syndrome: Case Report and Literature Review.

Inferior vena cava (IVC) thrombosis is a rare complication of abdominal aortic aneurysm (AAA). A 70-year-old male patient of Italian origin presented with a 9.3 × 8.4 cm infrarenal AAA, which was treated by endovascular aortic repair (EVAR). He reported a history of ulcerative colitis and was on prednisolone 80 mg daily. Seven weeks postoperatively the patient was readmitted with a deep vein thrombosis including both iliac veins and IVC, and bilateral pulmonary embolism. Venous thrombectomy and decompression of the IVC were performed by partial resection of the aneurysm sac. A covered stent was intraoperatively placed in the left common iliac vein to treat compression of the left iliac vein (May-Thurner Syndrome). Enoxaparin (2 × 0.8 mg) and antiplatelet agent with aspirin were administered, as well as intermittent compression therapy to the left leg. This case report describes vena cava thrombosis as a rare complication after EVAR in a patient with May-Thurner syndrome.

Vismodegib hedgehog-signaling inhibition and treatment of basal cell carcinomas as well as keratocystic odontogenic tumors in Gorlin syndrome.

Vismodegib hedgehog signaling inhibition treatment has potential for reducing the burden of multiple skin basal cell carcinomas and jaw keratocystic odontogenic tumors. They are major criteria for the diagnosis of Gorlin syndrome, also called nevoid basal cell carcinoma syndrome. Clinical features of Gorlin syndrome are reported, and the relevance of hedgehog signaling pathway inhibition by oral vismodegib for maxillofacial surgeons is highlighted. In summary, progressed basal cell carcinoma lesions are virtually inoperable. Keratocystic odontogenic tumors have an aggressive behavior including rapid growth and extension into adjacent tissues. Interestingly, nearly complete regression of multiple Gorlin syndrome-associated keratocystic odontogenic tumors following treatment with vismodegib. Due to radio-hypersensitivity in Gorlin syndrome, avoidance of treatment by radiotherapy is strongly recommended for all affected individuals. Vismodegib can help in those instances where radiation is contra-indicated, or the lesions are inoperable. The effect of vismodegib on basal cell carcinomas was associated with a significant decrease in hedgehog-signaling and tumor proliferation. Vismodegib, a new and approved drug for the treatment of advanced basal cell carcinoma, is a specific oncogene inhibitor. It also seems to be effective for treatment of keratocystic odontogenic tumors and basal cell carcinomas in Gorlin syndrome, rendering the surgical resections less challenging.

Direct lymphangiography as treatment option of lymphatic leakage: indications, outcomes and role in patient's management.

BACKGROUND: To evaluate the effectiveness of lymphography as a minimally invasive treatment option of lymphatic leakage in terms of local control and to investigate which parameters influence the success rate. METHOD: This retrospective study protocol was approved by the ethic committee. Patient history, imaging data, therapeutic options and follow-up were recorded and retrospectively analyzed. Between June 1998 and February 2013, 71 patients (m:w = 42:29, mean age, 52.4; range 42­75 years) with lymphatic leakage in form of lymphatic fistulas (n = 37), lymphocele (n = 11), chylothorax (n = 13) and chylous ascites (n = 10)underwent lymphography. Sixty-four patients (90.1%) underwent successful lymphography while lymphography failed in 7 cases. Therapeutic success was evaluated and correlated to the volume of lymphatic leakage and to the volume of the applied iodized oil. RESULT: Signs of leakage or contrast extravasation were directly detected in 64 patients. Of 64 patients, 45 patients (70.3%) were treated and cured after lymphography. Based on the lymphography findings, 19 patients (29.7%) underwent surgical intervention with a completely occlusion of lymphatic leakage. The lymphatic leak could be completely occluded in 96.8% of patients when the lymphatic drainage volume was less than 200 mL/day (n = 33). Even when lymphatic drainage was higher than 200 mL/day (n = 31),therapeutic lymphography was still successful in 58.1% of the patients. CONCLUSION: Lymphography is an effective, minimally invasive method in the detection and treatment of lymphatic leakage. The volume of lymphatic drainage per day is a significant predictor of the therapeutic success rate.

Transarterial chemoembolization of unresectable systemic chemotherapy-refractory liver metastases from colorectal cancer: long-term results over a 10-year period.

The aims of the study were to evaluate therapeutic efficacy and to determine the prognostic factors for treatment success in patients with liver metastases from colorectal cancer (CRC) treated with transarterial chemoembolization (TACE). A total of 564 patients (mean age, 60.3 years) with liver metastases of CRC were repeatedly treated with TACE. In total, 3,384 TACE procedures were performed (mean, six sessions per patient). The local chemotherapy protocol consisted of mitomycin C alone (43.1%), mitomycin C with gemcitabine (27.1%), mitomycin C with irinotecan (15.6%) or mitomycin C with irinotecan and cisplatin (15.6%). Embolization was performed with lipiodol and starch microspheres. Tumor response was evaluated using magnetic resonance imaging or computed tomography. The change in tumor size was calculated and the response was evaluated according to the RECIST-Criteria. Survival rates were calculated according to the Kaplan-Meier method. Prognostic factors for patient's survival were evaluated using log-rank test. Evaluation of local tumor control showed partial response in 16.7%, stable disease in 48.2% and progressive disease in 16.7%. The 1-year survival rate after chemoembolization was 62%, the 2-year survival rate was 28% and the 3-year survival rate was 7%. Median survival from the start of chemoembolization treatment was 14.3 months. The indication (p = 0.001) and initial tumor response (p = 0.015) were statistically significant factors for patient's survival. TACE is a minimally invasive therapy option for controlling local metastases and improving survival time in patients with hepatic metastases from CRC. TN stage, extrahepatic metastases, number of lesions, tumor location within the liver and choice of chemotherapy protocol of TACE are none significant factors for patient's survival.

Pediatric primary and metastatic neuroblastoma: MRI findings: pictorial review.

Magnetic resonance imaging (MRI) has become one of the most valuable modalities for initial and follow-up imaging of suspected or known neuroblastoma (NBL) owing to its excellent inherent contrast, lack of ionizing radiation and multiplanar imaging capability. Importantly, NBL has a variable appearance on different imaging modalities, and this is particularly pertinent to MRI. MRI is a cornerstone for management of NBL, providing essential information at initial presentation regarding diagnosis, staging, resectability and relation to vital structures. It can also define the extent of residual disease after surgical resection or assess the efficacy of treatment. Follow-up MRI is frequently performed to ensure sustained complete remission or to monitor known residual disease. This pictorial review article aims to provide the reader with a concise, yet comprehensive, collection of MR images of primary and metastatic NBL lesions with relevant correlation with other imaging modalities.

Assessment of surgically assisted rapid maxillary expansion regarding pterygomaxillary disjunction using thin volume-rendering technique: in variance analysis and in reliability, accuracy, and validity.

PURPOSE: To assess surgically assisted rapid maxillary expansion (SARME) with or without pterygomaxillary disjunction using a thin volume-rendering technique in variance analysis and in reliability, accuracy, and validity. MATERIALS AND METHODS: Thin volume-rendered images of 68 patients were evaluated preoperatively and 2.87 ± 1.59 months after expansion with respect to dentoskeletal effects. RESULTS: Variance analysis of SARME with pterygomaxillary disjunction showed an important decrease in transverse widening and segmental outward inclination and an increase in vestibular bone plate thickness (premolars) in patients younger than 20 years with bone-borne devices; the greatest increase in transverse widening was in patients with 3-segment osteotomy and tooth-borne devices. Analysis of SARME without pterygomaxillary disjunction showed an important decrease in transverse widening and segmental inward inclination in patients older than 20 years with bone-borne devices; the greatest pterygoid lateral bending was in patients with 2-segment osteotomy and bone-borne devices. CONCLUSION: The performance of pterygomaxillary disjunction should depend on patient age (ie, treatment with pterygomaxillary disjunction in those >20 years old; treatment without pterygomaxillary disjunction in those <20 years old). Patients with pterygomaxillary disjunction, 3-segment osteotomy, and tooth-borne devices tended to show an increase in transverse widening but at the price of greater attachment loss. Patients younger than 20 years with pterygomaxillary disjunction and bone-borne devices tended to show an increase in vestibular bone plate (premolars) but at the price of decrease in transverse widening.

Different imaging techniques in the head and neck: Assets and drawbacks.

In this review, the gold standard imaging techniques for the head and neck and the latest upcoming techniques are presented, by comparing computed tomography (CT), magnetic resonance imaging and positron emission tomography-CT, as well as ultrasound, depending on the examined area. The advantages and disadvantages of each examination protocol are presented. This article illustrates the connection between the imaging technique and the examined area. Therefore, the head and neck area is divided into different sections such as bony structures, nervous system, mucous membranes and squamous epithelium, glandular tissue, and lymphatic tissue and vessels. Finally, the latest techniques in the field of head and neck imaging such as multidetector CT, dual-energy CT, flash CT, magnetic resonance angiography, spectroscopy, and diffusion tensor tractography using 3 tesla magnetic resonance are discussed.

Secondary mandibular reconstruction after oral squamous cell carcinoma resection: clinical reevaluation of transport disk distraction osteogenesis.

Besides bone grafting, transport disk distraction osteogenesis (TDDO) is an alternative approach that can be used for the reconstruction of the mandibular arch after neoplastic surgery. Although several animal experiments are reporting about the applicability of this technique, little is known about its long-term success in human beings. In this study, we report about the successful treatment of patients with defects of their mandibular arch due to tumor resection by means of the external bifocal TDDO. A total of 7 patients (n = 3 with lateral, n = 4 with anterior defects) were followed up for a mean period of 56 months. Although neither adjuvant nor neoadjuvant chemotherapy negatively influenced callus formation, prereconstructive radiation with a dose of 51 Gy led to an insufficient callus formation. The reconstruction of anterior defects was unsatisfying because tensions from the soft tissue on the fragile and rubber-like callus negatively influenced the natural arch shaping.In these cases, additional surgery was often required. However, reconstruction of lateral defects of the mandibular arch was more successful and resulted in functional bone with good quality, in which dental implants could be inserted. The results of this study emphasize that TDDO by means of bifocal distraction provides functional bone comparable to residual bone.Lateral defects of mandibular arch can be better reconstructed, whereas anterior defects often require additional surgery.

Autoimmune pancreatitis in an 11-year-old boy.

We report a case of histopathologically proven autoimmune pancreatitis in an 11-year-old boy. Abdominal US and MRI showed a focal swelling of the pancreatic head, the latter also showing delayed contrast enhancement. There was diffuse irregular pancreatic duct narrowing, compression of the intrapancreatic common bile duct, and mild proximal biliary dilatation on MR cholangiopancreatography. Laboratory results revealed normal serum IgG and subclass 4 with negative autoimmune antibodies, and slightly elevated carbohydrate antigen 19-9. This highlights the differentiation of autoimmune pancreatitis from pancreatic head cancer and, to a lesser extent, other forms of pancreatitis in children.

Virtual endoscopy of the tracheo-bronchial system: sub-millimeter collimation with the 16-row multidetector scanner.

The purpose of this study was to evaluate the scope of sub-millimeter collimation reconstruction parameters using 16-row computer tomography and ECG triggering on image quality in virtual bronchoscopy. Thirty-two patients (5 women, 27 men, mean age 66.6+/-1.4) who had been admitted for coronary artery bypass graft surgery underwent CT examination of the thorax (Sensation 16, Siemens, Inc., Forchheim, Germany). All patients were examined with 16x0.75-mm collimation. Image reconstruction was performed for two groups. In group A ( n=32), slice thickness of 1.5 mm and an overlap of 0.75 mm were used. In group B ( n=32), slice thickness of 0.75 mm and an overlap of 0.4 mm were applied. Retrospective ECG triggering was performed in all patients. The maximum order of recognizable bronchi was determined in each data set. In addition to assessing the maximum order of bronchial bifurcation, bronchial diameter was determined in truly perpendicular sections in each patient. For every segment proximal to a bifurcation, image quality was subjectively graded as poor (grade 1), moderate (grade 2) or good (grade 3). The observers were asked to identify the minimum cardiac movement ECG-triggered image sets assuming that they would be of better quality than the maximum cardiac movement ECG-triggered image sets. The Mann-Whitney U-test and the Fisher's Exact Test were used for statistical evaluation. In group A, a mean of 4.8+/-0.2 bifurcations was ascertained vs. 6.5+/-0.3 bifurcations in group B [ P<0.0003]. For bronchial diameters in group A, a mean of 7.5+/-0.4 mm was determined vs. 4.6+/-0.4 mm in group B [ P<0.0001]. In group B, two independent radiologists observed a significant shift to better image quality in all segments evaluated [ P<0.006 to P<0.000001]. Motion artifacts were judged as being significantly reduced by minimum cardiac movement ECG-triggering in group B [observer 1: P=0.0007 (20/32); observer 2: P=0.008 (18/32)], but not in group A [observer 1: P=0.286 (13/32); observer 2: P=0.123 (16/32)]. Sub-millimeter collimation and minimum cardiac movement ECG-triggered data acquisition allow deeper penetration into the tracheo-bronchial system allowing visualization of the bronchial surface down to diameters below 5 mm in certain cases up to the eighth bifurcation. Along with an enhanced visualization as such, better image quality is acquired in all segments evaluated. Trade off between better image quality, of doubtful diagnostic consequence, and much higher irradiation dose must be made.