Does gamma-glutamyltransferase correlate with liver tumor burden in neuroendocrine tumors?

PURPOSE: In patients with neuroendocrine tumors (NETs) and liver metastases, increased gamma-glutamyltransferase (GGT) is commonly assumed as an indicator for progressive disease. To date, however, empirical data are lacking. This study aimed to investigate associations between GGT and liver tumor burden. In longitudinal analyses, associations of GGT and radiographic responses of liver metastases under therapy were investigated. METHODS: The cross-sectional sample consisted of 104 patients who were treated at the University Medical Center Hamburg-Eppendorf from 2008 to 2021 (mean age 62.3 ± 12.6 years, 58.7% male). GGT and liver imaging were identified in a time range of 3 months. Radiologic reassessments were performed to estimate liver tumor burden. In a separate longitudinal sample (n = 15), the course of GGT levels under chemotherapy was analyzed. Data were retrospectively analyzed with a univariate ANOVA, linear regression analyses, and Wilcoxon tests. RESULTS: Of 104 cross-sectionally analyzed patients, 54 (51.9%) showed a GGT elevation. GGT levels and liver tumor burden were positively correlated (p < 0.001), independently from age, gender, primary tumor location, grading, and cholestasis. Notably, GGT increase was associated with a liver tumor burden of >50%. In the longitudinal sample, 10 of 11 patients with progressive disease showed increasing GGT, whereas 4 of 4 patients with regressive disease showed declining GGT. CONCLUSION: Our findings indicate that GGT is associated with liver tumor burden. Over the course of therapy, GGT appears to change in line with radiographic responses. Further longitudinal studies with larger sample sizes are required to define GGT as a reliable marker for tumor response.

Association of medial collateral ligament complex injuries with anterior cruciate ligament ruptures based on posterolateral tibial plateau injuries.

BACKGROUND: The combined injury of the medial collateral ligament complex and the anterior cruciate ligament (ACL) is the most common two ligament injury of the knee. Additional injuries to the medial capsuloligamentous structures are associated with rotational instability and a high failure rate of ACL reconstruction. The study aimed to analyze the specific pattern of medial injuries and their associated risk factors, with the goal of enabling early diagnosis and initiating appropriate therapeutic interventions, if necessary. RESULTS: Between January 2017 and December 2018, 151 patients with acute ACL ruptures with a mean age of 32 ± 12 years were included in this study. The MRIs performed during the acute phase were analyzed by four independent investigators-two radiologists and two orthopedic surgeons. The trauma impact on the posterolateral tibial plateau and associated injuries to the medial complex (POL, dMCL, and sMCL) were examined and revealed an injury to the medial collateral ligament complex in 34.4% of the patients. The dMCL was the most frequently injured structure (92.2%). A dMCL injury was significantly associated with an increase in trauma severity at the posterolateral tibial plateau (p < 0.02) and additional injuries to the sMCL (OR 4.702, 95% CL 1.3-133.3, p = 0.03) and POL (OR 20.818, 95% CL 5.9-84.4, p < 0.0001). Isolated injuries to the sMCL were not observed. Significant risk factors for acquiring an sMCL injury were age (p < 0.01) and injury to the lateral meniscus (p < 0.01). CONCLUSION: In about one-third of acute ACL ruptures the medial collateral ligament complex is also injured. This might be associated with an increased knee laxity as well as anteromedial rotational instability. Also, this might be associated with an increased risk for failure of revision ACL reconstruction. In addition, we show risk factors and predictors that point to an injury of medial structures and facilitate their diagnosis. This should help physicians and surgeons to precisely diagnose and to assess its scope in order to initiate proper therapies. With this in mind, we would like to draw attention to a frequently occurring combination injury, the so-called "unlucky triad" (ACL, MCL, and lateral meniscus). Level of evidence Level III Retrospective cohort study.

Longitudinal follow-up by MR angiography reveals progressive dilatation of the distal aorta after aortic root replacement in Marfan syndrome.

OBJECTIVES: To define and compare growth rates of the distal aorta in Marfan patients with and without aortic root replacement using serial MR angiography (MRA). METHODS: We retrospectively included 136 Marfan patients with a total of 645 MRAs who underwent a median of five MRAs (range: 2-13) at 1.5 T and 3 T in annual intervals. Of these, 41 patients (34.8 ± 12 years) had undergone aortic root replacement. The remaining 95 patients (29.0 ± 17 years) still had a native aorta and served as the control group. Thoracic aortic diameters were independently measured at eleven predefined levels. Estimated growth rates were calculated using a mixed effects model adjusted for sex, age, BMI, and medication. RESULTS: Marfan patients with aortic root replacement revealed the highest mean estimated growth rate in the proximal descending aorta (0.77 mm/year, CI: 0.31-1.21). Mean growth rates at all levels of the distal thoracic aorta were significantly higher in patients with aortic root replacement (0.28-0.77 mm/year) when compared to patients without aortic root replacement (0.03-0.07 mm/year) (all p < 0.001). Antihypertensive medication, gender, and BMI had no significant impact on the distal aortic growth rates. CONCLUSION: Distal thoracic aortic diameters increase at a significantly higher rate in Marfan patients with aortic root replacement compared to Marfan patients without aortic root replacement. Further studies are warranted to investigate if the increased growth rate of the distal thoracic aorta after aortic root replacement is caused by altered hemodynamics due to the rigid aortic root graft or due to the general genetic disposition of post-operative Marfan patients. CLINICAL RELEVANCE STATEMENT: High growth rates of the distal aorta after aortic root replacement underline the need for careful life-long aortic imaging of Marfan patients after aortic root replacement. KEY POINTS: • Aortic growth rates in Marfan patients with aortic root replacement are highest in the mid-aortic arch, the proximal- and mid-descending aorta. • Growth rates of the distal thoracic aorta are significantly higher in Marfan patients with aortic root replacement compared to Marfan patients without aortic root replacement. • Antihypertensive medication, gender, and BMI have no significant impact on distal aortic growth rates in Marfan patients.

Bi-planar calibration method for templating of hip joint arthroplasty: phantom study and proof of concept.

PURPOSE: Calibration of radiographs is a critical step in digital templating for hip arthroplasty. Calibration errors of > 1.5% lead to over- or undersizing of the templated implants and may affect logistics and patient safety. Contemporary calibration methods are known to be imprecise with average errors of 6.5% and wide variance. A novel bi-planar radiograph-based calibration method is proposed, and a phantom study was conducted as proof of concept. METHODS: A spherical external calibration marker (ECM) is placed in front of the pubic symphysis of a pelvic bone model at twelve different positions. For each marker position, standard anteroposterior radiographs and four corresponding lateral radiographs with different degrees of rotation (0°-30°) are taken (overall, 60 radiographs). Calibration factors are calculated for an internal calibration marker (ICM) at the centre of the right hip (reference) and the ECM using a novel algorithm. Rotation and marker positions simulate foreseeable use errors and misplacements and aim to test robustness of the method against these errors. RESULTS: ECM calibration factor was 125.9% (range 124.7-127.2), and the mean ICM calibration factor was 126.6% (range 126.2-127.1) ([Formula: see text]). Four images (8.3%) were beyond the 1% error threshold (all with 30° rotation). The mean difference was 0.79% (SD 0.49). CONCLUSION: The bi-planar method precisely predicts the true calibration factor of the hip joint plane under various conditions. In lateral radiographs, rotation of up to 20° did not adversely affect the precision and all images had calibration errors below the threshold for clinical significance.

Spleen volume and length determined by computed tomography impact outcome after allogeneic stem cell transplantation for myelofibrosis.

Splenomegaly is a hallmark of myelofibrosis (MF), and reports on the impact of spleen size on the outcome of allo-HSCT have been conflicting, possibly due to differences in methods of assessment. We retrospectively analysed the impact of spleen volume and length measured by computed tomography on allo-HSCT outcome in 93 patients, 74% of whom had prior ruxolitinib treatment. Median spleen volume and length were 1.58 dm3 and 20 cm, respectively. We found a strong correlation between spleen volume and length (Pearson's r = 0.95, p < 0.001), Spearman (rho = 0.96, p < 0.001). After a median follow-up of 41.7 months, 5-year overall and disease-free survival were 66% and 59%, respectively. Spleen size did not impact overall survival or non-relapse mortality. Larger spleen volume and length as continuous variables were associated with slower platelet and leucocyte engraftment and a higher risk of disease relapse in univariate and multivariate analyses. Spleen length measured precisely by imaging is a good surrogate for spleen volume. In the era of JAK inhibitors, larger spleen size reflects advanced disease in MF and is associated with an increased risk of relapse but has no impact on non-relapse mortality and overall survival after allo-HSCT.

Pre-interventional assessment of right renal to right adrenal vein distance: Impact on procedure time and radiation dose in adrenal vein sampling.

PURPOSE: Adrenal vein sampling (AVS) is the reference standard for evaluation of lateralized hormone production in primary aldosteronism. We aimed to investigate the impact of pre-interventional right renal vein (RRV) to right adrenal vein (RAV) distance measurement on fluoroscopy time, contrast agent exposure and radiation dose during AVS. MATERIALS AND METHODS: Forty-five patients with primary aldosteronism undergoing AVS were enrolled in our retrospective study and divided into three groups. In the group "ruler" (n = 14), RRV-RAV-distances were determined pre-interventionally by cross-sectional imaging (CT/MRI) and AVS was performed by one interventional radiologist with limited experience in AVS. CT/MRI-derived and fluoroscopy-derived RRV-RAV-distances were correlated for aimed cannulation of the RAV. Patients in group "no ruler" (n = 24, three interventional radiologists with limited experience in AVS) and in group "expert", (n = 7, one expert interventional radiologist) underwent AVS without pre-interventional estimation of RRV-RAV-distances. Procedure parameters (fluoroscopy time, contrast agent volume, radiation dose) of group "ruler" were compared to both other groups by Kruskal-Wallis rank-sum test. RESULTS: Correlation of CT/MRI-derived and fluoroscopy-derived RRV-RAV-distances was good (r = 0.74;p = 0.003). The median RRV-RAV-distance was 4.5cm at CT/MRI (95%-CI:4.2-5.0cm) and 4.0cm at fluoroscopy (95%-CI:3.8-4.5cm). Fluoroscopy time (p<0.0001), contrast agent exposure (p = 0.0003) and radiation dose (air kerma and dose area product both p = 0.038) were significantly lower in group "ruler" compared to group "no ruler" (all p<0.05), and similar to group "expert" (all p>0.05). CONCLUSIONS: CT/MRI-derived pre-interventional renal-adrenal vein distance measurements correlate well with angiographic distance measurements. Pre-interventional estimation of the RRV-RAV-distance allows for aimed cannulation of the RAV with potential reduction of fluoroscopy time, contrast agent exposure and radiation-dose during AVS.

The Influence of Surgical Realignment Procedures on Dynamic Patellar Tracking: A Dynamic Magnetic Resonance Imaging-Controlled Feasibility Study.

Persisting patellar maltracking following surgical realignment often remains unseen. The aim of this study was to analyze the effects of realignment procedures on patellofemoral kinematics in patients with patellofemoral instability (PFI) and patellofemoral maltracking (PM) by using dynamic magnetic resonance imaging (MRI). Patients planned for surgical patellar realignment due to PFI and a clinically and radiologically apparent PM between December 2019 and May 2022 were included. Patients without PM, limited range of motion, joint effusion, or concomitant injuries were excluded. Dynamic mediolateral translation (dMPT) and patella tilt (dPT) were measured preoperatively and three months postoperatively. In 24 patients (7 men, 17 women; mean age 23.0 years), 10 tibial tubercle transfers, 5 soft tissue patella tendon transfers, 6 trochleoplasties, 3 lateral lengthenings, 1 varizating distal femoral osteotomy (DFO), and 1 torsional DFO were performed. At final follow-up, dMPT (from 10.95 ± 5.93 mm to 4.89 ± 0.40 mm, p < 0.001) and dPT (from 14.50° ± 10.33° to 8.44° ± 7.46°, p = 0.026) were significantly improved. All static radiological parameters were corrected to physiological values. Surgical patellar realignment contributed to the significant improvement of patellofemoral kinematics, with an approximation to normal values. The postoperative application of dynamic MRI allowed for a quantification of the performed correction, allowing for a postoperative control of success.

[Intimal pulmonary sarcoma: A case report of a rare differential diagnosis of chronic thromboembolic pulmonary hypertension]. / Das intimale Sarkom der Pulmonalarterie ­ Fallbericht einer seltenen Differenzialdiagnose der chronisch thromboembolischen pulmonalen Hypertonie.

Pulmonary angiosarcoma is a rare and malignant disease of the blood vessels. Initially, it can be misdiagnosed as chronic thromboembolic hypertension (CTEPH). In CTEPH, there is increased pressure and resistance of the pulmonary arteries following persistent obstruction of pulmonary circulation from (recurrent) thromboembolism despite adequate anticoagulative treatment.A 76-year-old patient was referred to our centre for pulmonary hypertension after a central, left-sided, subacute pulmonary thromboembolism had been observed 7 months earlier. It was treated with apixaban, but the patient described persistent dyspnoea and cough. We observed severely reduced diffusion capacity, ineffective ventilation during cardiopulmonary exercise testing and right heart strain on echocardiograph, signs that are in agreement with suspected CTEPH. Computer tomography of the chest showed a persistent, size-constant obliteration of the left main pulmonary artery, and ventilation perfusion scan confirmed complete interruption of perfusion. We suspected malignancy; PET-CT scan confirmed metabolically active lesions. Histopathological examination of a sample obtained from the lesion by endobronchial ultrasound-guided needle aspiration showed a sarcomatous tumour with amplification of the MDM2-gene. We diagnosed an intimal angiosarcoma of the left pulmonary artery and referred the patient to pneumectomy.Angiosarcoma of the pulmonary arteries is a rare differential diagnosis of persistent thrombotic lesion and suspected CTEPH. In 2015 there were less than 300 cases described.Pulmonary angiosarcoma should be considered if: lesion occupies the entire lumen of pulmonary arteries with dilatation, contrast enhancement and infiltration of the wall in radiological examination, FDG-PET CT reveals metabolically active lesions, no pulmonary thromboembolism was documented in the anamnesis, increase in size is seen despite anticoagulation, patient presents with B symptoms.Diagnosis confirmed by biopsy, resection of tumour and removal of metastases is the therapeutic standard. Median survival remains poor. Further research is needed for improved diagnosis and treatment.

Radiation dose reduction during adrenal vein sampling using a new angiographic imaging technology.

To compare the patient radiation doses during angiographic selective adrenal vein sampling (AVS) before and after an imaging technology upgrade. In this retrospective single-center-study, cumulative air kerma (AK), cumulative dose area product (DAP), fluoroscopy time and contrast agent dosage were recorded from 70 patients during AVS. 35 procedures were performed before and 35 after an imaging processing technology upgrade. Mean values were calculated and compared using an unpaired student's t-test. DSA image quality was assessed independently by two blinded readers using a four-point Likert scale (1 = poor; 4 = excellent) and compared using Wilcoxon signed-rank test. After the technology upgrade we observed a significant reduction of 35% in AK (1.7 ± 0.7 vs. 1.1 ± 0.7 Gy, p = 0.01) and a significant reduction of 28% in DAP (235.1 ± 113 vs. 170.1 ± 94 Gy*cm2, p = 0.01) in comparison to procedures before the upgrade. There were no significant differences between the number of exposure frames (143 ± 86 vs. 132 ± 61 frames, p = 0.53), fluoroscopy time (42 ± 23 vs. 36 ± 18 min, p = 0.22), or the amount of contrast medium used (179.5 ± 84 vs. 198.1 ± 109 ml, p = 0.41). There was also no significant difference regarding image quality (3 (2-4) vs. 3 (2-4), p = 0.67). The angiographic imaging technology upgrade significantly decreases the radiation dose during adrenal vein sampling without increasing time of fluoroscopy or contrast volume and without compromising image quality.

Semi-quantitative magnetic resonance imaging scoring of the knee detects previous injuries in professional soccer players.

PURPOSE: The medical examination ("medical") is an important procedure in professional soccer since it has high economic relevance. In addition to clinical tests, magnetic resonance imaging (MRI) is used to assess joint health. In the present study, the reliability of semiquantitative knee MRI during the "medical" in professional soccer was tested, and its relationship with clinical data and days missed due to knee injury was observed. METHODS: In this cross-sectional study, between 2012 and 2019, 69 newly assigned players (age 18-35 years) from a professional soccer club underwent MRI (3.0 T) of both knee joints during their "medical". Reported knee injuries and previously missed days due to injury were obtained from player anamnesis and the "transfermarkt.com" database. Based on the established "Whole-Organ Magnetic Resonance Imaging Score" (WORMS), two independent radiologists graded the MRI results. Further evaluation was based on the mean score of both knees. RESULTS: The mean WORMS for all subjects was 13.9 (median 10.5, range 0-61). Players with previous injuries had significantly higher scores than players without reported injuries (22.1 ± 17.7 vs. 8.9 ± 4.4, p < 0.002). Three outliers (previously undetected injuries) in the group of players without reported injuries were observed (6.7%). The WORMS was significantly correlated with a prior knee injury (r: 0.424, p < 0.0001) and days missed due to injury (r: 0.489, p < 0.001). Age was correlated with the WORMS (r: 0.386, p < 0.001). In a linear regression model, prior injury was the only significant predictor of a high WORMS (p = 0.001). The WORMS was a significant predictor of days missed due to injury (p < 0.0002) and prior injury (sensitivity: 78%, specificity: 91%, p = 0.006). The intraclass correlation coefficient was excellent (0.89). CONCLUSION: Semiquantitative knee MRI for WORMS determination during the soccer "medical" is a robust and reliable method. Prior injury, even in players without documented trauma, was detected by the WORMS, and previously missed days due to injury were correlated with the semiquantitative MR knee score. LEVEL OF EVIDENCE: Level III.

Magnetic resonance angiography derived predictors of progressive dilatation and surgery of the aortic root in Marfan syndrome.

BACKGROUND: To identify magnetic resonance (MR) angiography derived predictors of progressive dilatation and surgery of the aortic root in Marfan syndrome. MATERIAL AND METHODS: We retrospectively included 111 patients (32.7±16.5 years, range: 7-75 years) with a total of 446 MR angiographies. Aortic diameter growth rates of the entire thoracic aorta and Z-scores were estimated from annual diameter measurements. Aortic root shape was subdivided into three different types: (T0) normal; (T1) localized dilatation; (T2) generalized aortic root dilatation. Aortic diameter, Z-score, age, and aortic root shape at baseline were tested as predictors of aortic root dilatation using a multivariate logistic regression model. RESULTS: The highest aortic growth rate was observed at the level of the sinuses of Valsalva. Higher aortic root diameters and Z-scores at baseline predicted an increased growth of the aortic root (p = 0.003 and p<0.001). Young age (<30 years) was a predictor for the increase of Z-scores when compared to patients ≥30 years (p = 0.019). 25/111 patients (22.5%) had a T0 aortic root shape, 59/111 patients (53.2%) had a T1 aortic root shape, and 27/111 patients (24.3%) had a T2 aortic root shape. Aortic root shape did not predict further aortic growth (p>0.05). However, significantly more patients undergoing surgery had a generalized aortic dilatation (19/28, 76.9%) than a localized aortic root dilatation (9/28, 32.1%) (p = 0.001). CONCLUSION: Larger baseline aortic root diameter and Z-score as well as young age predict solely progressive aortic root dilatation in Marfan patients. MR angiography derived type of aortic root shape does not predict aortic growth, but patients with generalized aortic root dilatation are referred more frequently for aortic surgery.

[Neoehrlichiosis as a cause of feaver of unknown origin]. / Neoehrlichiose als Ursache eines Fiebers unklarer Genese.

Establishing a diagnosis in cases of fever of unknown origin (FUO) in immunocompromised patients can be difficult. In 25-35% infectious diseases are the underlying cause. This article reports the case of a 74-year-old woman with a 5-month history of fever. Through open biopsy of the femoral shaft and microbiological analysis, a diagnosis of neoehrlichiosis could be established. After initiation of treatment with doxycycline, the symptoms quickly resolved resulting in a complete recovery.

Dynamic Mediolateral Patellar Translation Is a Sex- and Size-Independent Parameter of Adult Proximal Patellar Tracking Using Dynamic 3 Tesla Magnetic Resonance Imaging.

PURPOSE: To provide normal values for physiological patellofemoral tracking in a representative group of healthy individuals, as well as sex differences, using real-time 3T-magnetic resonance imaging (MRI) and to test for the reliability of the presented technique. METHODS: One hundred knees of healthy individuals with no history of patellofemoral symptoms were scanned with dynamic MRI sequences, during repetitive cycles of flexion (40°) and full extension. Within a 30-seconds time-frame, three simultaneous, transverse slices were acquired. Dynamic mediolateral patellar translation (dMPT) and dynamic patellar tilt (dPT) were measured on two occasions by two independent examiners. Common radiological parameters were measured using static MRI, and correlations were calculated. RESULTS: 100 knees (53 right, 47 left; age: 26.7 ± 4.4 years; BMI: 22.5 ± 3.1) of 57 individuals (27 females, 30 males) were included. Mean height was 170.1 ± 7.7 cm in women and 181.8 ± 6.4 cm in men. Average patella diameter was 37.9 ± 2.7 (95% CI 37.1-38.7) mm in women and 42.4 ± 3.2 (95% CI 41.5-43.3) mm in men. In females, the patellar diameters and intercondylar distances were significantly smaller than in males (P < .001). Radiological parameters for patellar maltracking were within the normal range. During the range of motion, mean dMPT was 1.7 ± 2.4 (95% CI .9-2.5) mm in females and 1.8 ± 2.7 (95% CI 1.1-2.6) mm in males (P = .766). Mean dPT was 1.3 ± 2.9° (95% CI .4-2.1°) in females and -0.2 ± 3.8° (95% CI -1.2-.9°) in males (P = .036). Neither dMPT nor dPT was correlated with height, BMI, or patellar diameter. Intercondylar distance correlated weakly with dPT (r = -.241; P = .041). Intra- and interrater reliability were excellent for dMPT and dPT. CONCLUSION: Dynamic mediolateral patellar translation is a size- and sex-independent parameter for proximal patellar tracking. In healthy individuals without patellofemoral abnormalities normal dMPT proximal to the trochlea groove was 1.7 ± 2.5 (1.2-2.2) mm, independent of size or sex. Normal dPT showed a dependency on sex and was 1.3 ± 2.9 (.4-2.1)° in women and -0.2 ± 3.8 (-1.2-0.9)° in men. LEVEL OF EVIDENCE: Level II, diagnostic study.

Localization Defines Streptozotocin/5-FU Response in Primary Pancreatic Neuroendocrine Tumours.

INTRODUCTION: Incidence of pancreatic neuroendocrine tumours (pNETs) is on the rise. The only curative treatment is surgical resection in localized or oligo-metastatic disease. However, patients may present with locally advanced or unresectable primary tumours. So far, no conversion therapy to achieve resectability has been established, which is partly due to lack of data on primary tumour response to therapies. Here, we specifically evaluate the primary tumour response to streptozocin/5-FU in a large cohort of metastatic pNET patients. METHODS: Five ENETS centres in Germany contributed 84 patients to the study cohort for retrospective analysis. RESULTS: Overall response rate (ORR) in primary tumours was 34% and disease control rate (DCR) 88%. ORR was different in metastases at 44% and DCR at 70%. Partial remission in primary tumours was more frequent among those located in pancreatic tail than that in pancreatic head (49% vs. 14%, p = 0.03). Correspondingly, metastases from tumours originating from pancreatic tail responded more frequently than metastases originating from pancreatic head (88.5% vs. 41.7%, p = 0.005). The median PFS of the primary tumours was longer than that in metastases (31 months vs. 16 months; p = 0.04). Considerable downsizing of the primary tumour was rare and occurred primarily in tumours located in the pancreatic tail. CONCLUSION: STZ/5-FU can achieve disease stabilization in a high proportion of metastatic pNET patients. In the majority of cases however it does not induce substantial downsizing of the primary tumour, thus possibly limiting its potential as conversion chemotherapy. Furthermore, the difference in response rate observed between different primary tumour locations warrants further exploration.

Accuracy of preoperative CT staging of acute colonic diverticulitis using the classification of diverticular disease (CDD) - Is there a beneficial impact of water enema and visceral obesity?

PURPOSE: We evaluated the accuracy of preoperative CT in staging colonic diverticulitis (ACD) by using the classification of diverticular disease (CDD) and investigated the diagnostic impact of water enema (WE) and visceral obesity. METHODS: In this retrospective study, the radiological and hospital information system was searched for patients who underwent CT for clinically suspected ACD prior to surgery between 2009 and 2019. From the initial population (n = 164), we included 155 patients (94.5 %) (85 women; mean age: 58 ±â€¯13 years) matching the following inclusion criteria: i.) clinically suspected ACD, ii.) i.v. contrast-enhanced CT, iii.) surgery for ACD within 1 week after CT, iv.) histopathological report that proved ACD. The remaining 9 patients (5.5 %) were excluded because histopathological reports were lacking (n = 3) or CT was performed without intravenous contrast agent (n = 6). WE (+ butylscopolamine i.v.) was performed in 93 patients (group A, 60 %). 62 patients (group B, 40 %) had no WE. Visceral-to-subcutaneous fat ratio (V/S) was determined for each patient. Two radiologists blinded for final diagnosis independently staged ACD according to CDD and assessed prevalence and confidence ratings of ACD-related CT-findings: pericolonic fat stranding, covered- and free-perforation, local and generalized peritonitis, abscess. Interobserver-agreement of CT-findings were assessed and effects of WE and V/S ratio on the diagnostic accuracy of CT with surgical and histopathological findings as reference were determined by calculating a logistic regression model. RESULTS: CT-staging showed high accuracy (94 %) and excellent interrater-correlation (ICC 0.96) for staging ACD. WE had no positive impact neither on diagnostic accuracy of staging, nor on confidence ratings of ACD-related CT-findings (all p > 0.5). Confidence ratings were significantly higher in examinations without WE for perforation, peritonitis as well as abscesses (all p < 0.5). Confidence ratings for the assessment of local peritonitis improved significantly with higher V/S (p = 0.049). The increase of V/S significantly correlated with the probability for correct CDD staging of ACD in CT (p = 0.023). CONCLUSION: Increase of visceral obesity significantly improves accuracy of CT in preoperative staging acute colonic diverticulitis. However, independently of the degree of visceral obesity, water enema has no diagnostic benefit and may therefore be omitted. Overall, CT proves high accuracy in preoperative staging ACD using the classification of diverticular disease. LEVEL OF EVIDENCE: Retrospective study, observational study.

Intraindividual comparison of 1.5 T and 3 T non-contrast MR angiography for monitoring of aortic root diameters in Marfan patients.

BACKGROUND: Reproducible aortic diameter measurements are crucial for assessment of aortic growth and aneurysm formation in patients with Marfan syndrome. The objective of this study was to perform an intraindividual comparison of aortic measurements at 1.5 T and 3 T using non-contrast magnetic resonance angiography (MRA) in pre-surgical and post-surgical Marfan patients. METHODS: Forty consecutive Marfan patients were retrospectively evaluated by ECG-gated 2D balanced steady-state free precession (bSSFP) MRA at 1.5 T and 3 T after 363 ± 58 days. 24 patients were before and 16 patients after aortic root surgery. Two readers independently measured aortic diameters at seven aortic levels and rated the image quality/image artifacts (1 = poor/severe, 4 = excellent/none). Contrast-to-noise ratio (CNR) and signal intensity slopes between aortic lumen and vessel walls were semiautomatically determined. RESULTS: In pre-surgical Marfan patients, interobserver agreement of aortic root diameter measurements was significantly higher at 3 T compared to 1.5 T (p < 0.05). In post-surgical Marfan patients, image quality and artifacts were significantly worse at 3 T compared to 1.5 T (p < 0.05). CNR was higher at 3 T compared to 1.5 T at all aortic levels. Significantly steeper slopes of signal intensity curves were observed at 3 T at all aortic levels (p < 0.001). CONCLUSIONS: In pre-surgical Marfan patients, non-contrast MRA provides higher reproducibility of aortic diameter measurements at 3 T compared to 1.5 T. In post-surgical Marfan patients, metallic implants result in significantly worse imaging artifacts and reduced image quality at 3 T compared to 1.5 T. Therefore, we propose to monitor the thoracic aorta with non-contrast MRA at 3 T in pre-surgical Marfan patients and at 1.5 T in post-surgical Marfan patients.

Diagnostic Imaging of Patellofemoral Instability. / Bildgebende Diagnostik der patellofemoralen Instabilität.

BACKGROUND: Throughout the literature, patellofemoral instability (PI) is defined as an increased risk of re-/luxation of the patella within the patellofemoral joint (PFJ). In most patients it is caused by traumatic patella luxation or the existence of a range of predisposing anatomic risk factors leading to an unphysiological movement sequence within the PFJ also known as patellofemoral maltracking. In order to provide an individualized therapy approach, clinical and radiological evaluation of those risk factors of variable magnitude becomes essential. Diagnostic imaging such as magnetic resonance imaging (MRI), plain radiography, and computed tomography (CT) are straightforward diagnostic tools in terms of evaluation and treatment of PI. METHOD: In this review we performed a precise analysis of today's literature concerning the radiological evaluation of anatomic risk factors leading to PI. The purpose of the review is to present a logical compilation of the different anatomical risk factors causing PI and provide a straight overview of valuable radiological imaging techniques. RESULTS AND CONCLUSION: PI is frequently based on a multifactorial disposition. The most relevant predisposing risk factors are trochlea dysplasia, rupture of the medial patellofemoral ligament (MPFL), patella alta, abnormal tibial tubercle to trochlea groove distance (TT-TG), femoral torsion deformities, and genu valgum. Although plain X-rays may provide basic diagnostic value, cross-sectional imaging (MRI, CT) is the standard radiological tool in terms of evaluation and detection of severity of predisposing anatomic variants leading to PI. KEY POINTS: · Based on today's literature, PI is characterized as an increased risk of patella re-/luxation within the PFJ.. · Underlying anatomic risk factors of variable magnitude mark the pathological cause of PI.. · Modern diagnostic imaging (MRI and CT) permits straightforward diagnosis of the typical features in terms of PI.. · To provide an individualized therapy approach, precise radiological evaluation and determination of the severity of predisposing anatomic anomalies are essential.. CITATION FORMAT: · Maas KJ, Warncke ML, Leiderer M et al. Diagnostic Imaging of Patellofemoral Instability. Fortschr Röntgenstr 2021; 193: 1019 - 1033.

Diagnostic yield of cone beam computed tomography for small foreign body detection in the hand in comparison with radiography, MSCT and MRI: an ex vivo study.

INTRODUCTION: Detection of symptomatic foreign bodies (FB) after penetrating hand injuries can be challenging. Multiplanar radiography is most frequently used for FB detection and may be complemented by multislice computed tomography (MSCT) if suspected FBs cannot be identified and clinical symptoms are persisting. Cone beam computed tomography (CBCT) is a promising imaging modality for traumatology aside from fracture detection. The aim of this study was to evaluate the diagnostic yield of CBCT for different small FBs in the hand in comparison with radiography, MSCT and magnetic resonance imaging (MRI). METHODS: In ten cadaveric hands of voluntary body donors, 20 different FBs (metal, glass, stone, wood, thorn) in predefined sizes (0.5, 1 and 2mm) were randomly placed in the central hand and the basal phalanges. All hands were imaged using radiography, 256-slice CT, CBCT, and 3T MRI. A total of 200 subcutaneous and intramuscular particles were analyzed for their visibility by two observers at two time points. The Cohens Kappa coefficient was calculated as a measure of interobserver agreement and intraobserver reliability. The particle detection rate between different imaging modalities was compared using McNemar Chi2-tests. RESULTS: CBCT and MSCT provided a higher detection rate (94.6% and 86.3%) for detecting metal, glass and stone particles compared to standard radiography (70.0%; each p<0.001). MRI did not provide a diagnostic benefit. Wood particles and thorns were not reliably recognizable by any imaging technique. The interobserver agreement (K=0.768; p<0.001) and the intraobserver reliability for both observers (K1=0.914 and K2=0.907; p<0.001) were good. The dose length product (DLP) was 2-fold lower in CBCT than in MSCT (39.2 ± 2.1 vs. 81.4 ± 2.9 mGy*cm; p<0.001). CONCLUSIONS: In this ex vivo study, CBCT provided a high detection rate for small metal, glass, and stone particles while the radiation exposure was significantly lower compared to MSCT. These results suggest that CBCT instead of MSCT seems a reasonable option in supplementary diagnostics to exclude of FBs. The primary use of CBCT instead of radiography may be considered for symptomatic patients with expected small radiopaque particles <1mm. Organic FBs can be visualized indirectly in MRI and CBCT/MSCT by entrapped surrounding air. LEVEL OF EVIDENCE: Level I, diagnostic study.

Magnetic resonance imaging of midtarsal sprain: Prevalence and impact on the time of return to play in professional soccer players.

BACKGROUND: Ankle sprain is a common injury in professional soccer, but to date midtarsal sprain has not been investigated in this context. The purpose of this study was to determine the prevalence of midtarsal sprain by MRI and to assess its impact on the time of return to play in professional soccer players. METHODS: We included 52 professional soccer players who underwent 59 MRI examinations after acute ankle trauma between January 2012 and September 2019. Images were retrospectively reviewed in consensus by two radiologists for assessment of midtarsal sprain and ankle sprain. Ligaments were graded as i) normal, ii) partial tear, or iii) complete tear. Time to return to play (RTP) for each athlete was retrieved from team medical records. A Kruskal-Wallis test and Dunn's pairwise tests were used to calculate differences in RTP time between groups with i) isolated midtarsal sprain, ii) isolated lateral ankle sprain, and iii) combined midtarsal and lateral ankle sprain. RESULTS: MRI revealed isolated ankle sprain in 24 of 59 MRI examinations (40.6 %). Acute midtarsal ligament injury was present in 15 examinations (25.4 %). Four of the 15 examinations (26.7 %) had isolated midtarsal injuries and eleven of the 15 examinations (73.3 %) had concomitant ankle sprain. RTP time was 39 days (range 9-70 days) for isolated midtarsal sprain. RTP time was significantly higher for athletes with combined ankle and midtarsal sprain (47 days, range 15-74 days) when compared to athletes with isolated ankle sprain (24 days, range 2-59 days) (p = .019). CONCLUSION: Our MRI study reveals that midtarsal sprain is a frequent injury in professional soccer players with ankle sprain. Midtarsal ligament findings on MRI combined with evidence of lateral ankle sprain is associated with a longer time of return to play compared to isolated lateral ligament injuries. LEVEL OF EVIDENCE: Retrospective study, observational study.

Objective assessment of patellar maltracking with 3 T dynamic magnetic resonance imaging: feasibility of a robust and reliable measuring technique.

Patellofemoral maltracking predisposes the patellofemoral joint to instability. The purpose of this study was to provide a reliable dynamic magnetic resonance imaging (MRI) measuring technique for patellofemoral maltracking, and to investigate the influence of anatomical risk factors (AF) on patellar maltracking. Ten patients (2 males,8 females, average 19 years) with clinical maltracking and 20 controls (10 males,10 females,average 28 years) were examined with a dynamic, multi-slice gradient-echo MRI sequence, during repetitive flexion(40°) and full extension, in an open-chain-active-movement. In a 30-s time frame three simultaneous transverse slices were acquired. Dynamic mediolateral translation and dynamic tilt were measured at defined positions, by two independent examiners. Reproducibility was tested in a set of five knees. Common AFs for patellar maltracking (tibial-tuberosity-to-trochlear-groove-(TT-TG)-distances, trochlea-sulcus-angle, trochlea-sulcus-depth, lateral-trochlear-inclination and Caton-Deschamps-Index) were analyzed in consensus, using standard static MRI sequences. In patients, dynamic mediolateral translation was significantly greater in patients (12.4 ± 6.9 mm vs. - 0.1 ± 2.3 mm, p < 0.001) and the patella was positioned significantly more laterally (17.5 ± 6.9 mm vs. 3.1 ± 2.4 mm, p < 0.001) compared to controls. During movement, the patella tilted 16.3 ± 13.1° laterally in patients and 1.9 ± 4.3° medially in controls (dynamic tilt) (p < 0.002). All AFs were significantly different between patients and controls. Pathological TT-TG-distances, Caton-Deschamps-Indices and trochlea-sulcus-angles strongly correlated with dynamic patellar translation and dynamic patellar tilt (p < 0.001). In the patient population, the primary pathologies for maltracking were lateralized-tibial-tubercle (n = 5), trochlea dysplasia n = 2, patella alta (n = 3). Interrater-reliability for translation and tilt-measurement was excellent (0.971/0.976, 95% CIs 0.939-0.986/0.950-0.988). Dynamic MRI reliably differentiates between abnormal and physiological patellar tracking. Dynamic tracking and tilt strongly correlate with measurable AFs, which reinforces their clinical use and validates the presented technique.