Acute endometriosis-related sigmoid perforation in pregnancy- case report.

BACKGROUND: An acute abdomen is an emergency that requires accurate diagnosis and prompt treatment. In pregnancy, the process is even more challenging and sometimes the radiological findings are unclear. Moreover, endometriosis- related complications are rare, especially in previously unknown endometriosis. CASE PRESENTATION: We report on a case of acute endometriosis-related sigmoid perforation during pregnancy (34 weeks of gestation) due to a previously unknown deep intestinal infiltrating endometriosis with focal ulceration of the affected colonic mucosa. CONCLUSIONS: Despite the low relative risk, clinicians should be aware of possible endometriosis-associated complications in pregnancy with potentially life-threatening events, even in previously unknown endometriosis. Further studies should evaluate intestinal complications during pregnancy in relation to previous treatment of intestinal endometriosis (conservative vs. surgical).

Relevance and methods of interventional breast sonography in preoperative axillary lymph node staging.

Reduction of therapy-induced morbidity is an important goal for the improvement of the quality of breast cancer treatment. The introduction of sentinel lymph node biopsy (SLNB) significantly contributed to the reduction of surgery-induced morbidity in the shoulder-arm region. However, a clinically positive nodal status is still considered a contra-indication for SLNB. The current data constellation clearly shows that the clinical and also the sonographic malignancy assessment is insufficient for the accurate identification of the nodal status. A merely clinical and/or image-based appraisal of the axillary lymph node status would lead to overtreatment due to unnecessary axillary dissection in approximately 40 % of patients. In order to reduce the rate of unnecessary axillary dissection (AD), pretreatment interventional clarification is necessary to provide more detailed information about the histological condition of the lymph node. Comparing the currently available methods, fine needle aspiration (FNA) is the best in terms of cost and time requirement, practicability and complication rate. However, considering the sensitivity, it is inferior to ultrasound-guided core needle biopsy (CNB). Thus, a negative FNA outcome requires further clarification, which possibly can be performed with CNB. With a specificity of nearly 100 % and therefore a low rate of false positive cases for FNA, complete AD can be indicated by a positive FNA result. In the context of the interventional procedure, it must be stressed that FNA requires a high level of expertise on the part of both the examiner and the cytologist. The prerequisite for optimal interventional diagnostics of lymph nodes is an adequate sonographic assessment on the basis of standardized sonomorphological criteria.

Systematic analysis of parameters predicting pathological axillary status (ypN0 vs. ypN+) in patients with breast cancer converting from cN+ to ycN0 through primary systemic therapy (PST).

Optimization of axillary staging among patients converting from clinically node-positive disease to clinically node-negative disease through primary systemic therapy is needed. We aimed at developing a nomogram predicting the probability of positive axillary status after chemotherapy based on clinical/pathological parameters. Patients from study arm C of the SENTINA trial were included. Univariable/multivariable analyses were performed for 13 clinical/pathological parameters to predict a positive pathological axillary status after chemotherapy using logistic regression models. Odds ratios and 95%-confidence-intervals were reported. Model performance was assessed by leave-one-out cross-validation. Calculations were performed using the SAS Software (Version 9.4, SAS Institute Inc., Cary, NC, USA). 369 of 553 patients in Arm C were included in multivariable analysis. Stepwise backward variable selection based on a multivariable analysis resulted in a model including estrogen receptor (ER) status (odds ratio (OR) 3.916, 95% confidence interval (CI) 2.318-6.615, p < 0.001), multifocality (OR 2.106, 95% CI 1.203-3.689, p = 0.0092), lymphovascular invasion (OR 9.196, 95% CI 4.734-17.864, p < 0.001), and sonographic tumor diameter after PST (OR 1.034, 95% CI 1.010-1.059, p = 0.0051). When validated, our model demonstrated an accuracy of 70.2% using 0.5 as cut-point. An area under the curve of 0.81 was calculated. The use of individual parameters as predictors of lymph node status after chemotherapy resulted in an inferior accuracy. Our model was able to predict the probability of a positive axillary nodal status with a high accuracy. The use of individual parameters showed reduced predictive performance. Overall, tumor biology was the strongest parameter in our models.

[Mystery of alar ligament rupture: value of MRI in whiplash injuries--biomechanical, anatomical and clinical studies]. / Mysterium Ligamentum alare Ruptur: Stellenwert der MRT-Diagnostik des Schleudertraumas--biomechanische, anatomische und klinische Studien.

PURPOSE: Whiplash injury of the cervical spine is a frequent issue in medical expertise and causes enormous consequential costs for motor insurance companies. Some authors accuse posttraumatic changes of alar ligaments to be causative for consequential disturbances. MATERIALS AND METHODS: Review of recent studies on biomechanics, anatomical and clinical MR imaging. RESULTS: Biomechanical experiments can not induce according injuries of alar ligaments. Although MRI provides excellent visualization of alar ligaments, the range of normal variants is high. CONCLUSION: Biomechanical studies give no evidence of alar ligament involvement in whiplash disease. Using MRI, signal alterations of alar ligaments can hardly be differentiated from common normal variants. Functional MRI provides no diagnostic yield.

[Estimation of diffuse bone marrow infiltration of the spine in multiple myeloma: correlation of MRT with histological results]. / Beurteilbarkeit diffuser Knochenmarksinfiltrationen der Wirbelsäule bei multiplem Myelom: Korrelation von MRT-Befunden mit der Histologie.

PURPOSE: To determine the detection of diffuse bone marrow infiltration with MRI in comparison with histopathological findings. MATERIALS AND METHODS: MRI was performed on 45 patients with histologically proven multiple myeloma and on 30 healthy individuals. Three experienced radiologists read separately Tl-weighted SE sequences, STIR sequences and the combination of Tl-weighted SE and STIR sequences of the spine. Additionally, Tl-weighted SE sequences were obtained after gadolinium administration and the percentage increase in signal intensity was calculated. Bone marrow histology was used as gold standard for assessing the grade of infiltration. A dichotomous decision (infiltration yes/no) was made when assessing the MRI examinations. RESULTS: For the visual detection of diffuse infiltration, the best sensitivity was found with Tl-weighted SE sequences, achieving 71 % on average. The specificity was 89 %. The STIR sequences showed a sensitivity of 61 % and a specificity of 98 %, and the combination of Tl-weighted/STIR-sequences achieved a sensitivity of 65 % and a specificity of 94 %. In comparison with the histological findings, the sensitivity of the Tl-weighted sequences was 35 % for low-grade, 89 % for moderate and 100 % for high-grade infiltration. The application of contrast material with calculation of the percentage signal increase improved the detection by 7 %. CONCLUSION: The sensitivity of the visual detection of diffuse multiple myeloma with unenhanced MRI is limited for low-grade or moderate infiltration, whereas the sensitivity for high grade infiltration is reliable. The specificity is high and the diagnostic confidence improves after application of contrast material with calculation of the percentage increase in signal intensity.

Assessment of the position of the distal portion of the ulna in lateral projection radiographs of the wrist: analysis of the influence of pronation-supination and flexion-extension on the pisoscaphoid and the ulnotriquetral distances: a cadaver study.

RATIONALE AND OBJECTIVES: Accurate assessment of the distal radioulnar joint is of paramount importance for the detection of possible dislocation or subluxation. Using a cadaveric model, the authors attempted to establish a quantitative method that would allow identification of normal and abnormal distal radioulnar joint anatomy on well-positioned and rotated conventional radiographs. METHODS: Four cadaveric wrists, in which subsequent sectioning confirmed the absence of disease, and one cadaveric wrist with a circumscribed lesion of the triangular fibrocartilaginous complex were studied. Defined movements in flexion and extension (+/- 10 degrees, 20 degrees, 30 degrees ) and in pronation and supination (+/- 10 degrees, 20 degrees, 30 degrees ) as well as combined flexion/extension and pronation/supination were performed. The ulnotriquetral and the pisoscaphoid distances were assessed in each position. Correlation with cryosections was achieved. RESULTS: A strong linear correlation between the degree of pronation or supination and the pisoscaphoid and ulnotriquetral distances was noted. Flexion and extension produced no significant effect on the pisoscaphoid distance, but a defined shift of the ulnotriquetral distance occurred with increasing flexion and extension. CONCLUSIONS: If all parameters are taken into account, this correlation aids in estimating the degree of possible malpositioning of the wrist during radiography and the degree of subluxation of the distal radioulnar joint. Tabular data with parameters to correct for instances of malrotated images and to estimate the extent of dislocation or malrotation of the distal radioulnar joint are provided.

Imaging of spinal infection.

MR imaging is the modality of choice for the detection, staging, and differential diagnosis of inflammatory disorders of the spine. Infectious spondylitis is characterized by the involvement of two adjacent vertebrae and the intervening disk with severe BME and early destruction of the end plates. The disk space is narrowed and typically exhibits water-equivalent signal intensity on T2-weighted or STIR images. Prevertebral and epidural extensions, abscess formation, enhancement of the BME, the disk space, and the surrounding granulation tissue are well demonstrated by gadolinium-enhanced images. Cervical spondylitis frequently involves more than one level. Bone marrow abnormalities may be subtle at this level and increased signal intensity of the disk space on T2-weighted or STIR images is an important finding. The risk for neurologic complications is increased. Granulomatous infections caused by tuberculosis, brucellosis, fungi, and parasites, including hydatid disease (Echinococcus), are frequently associated with imaging findings different from those seen with nonspecific bacterial infection. In patients with chronic infectious spondylitis, diffuse reactive bone marrow changes with decreased signal intensity on T1-weighted images, increased signal intensity on T2-weighted and STIR images, and increased uptake after gadolinium administration may occur. This phenomenon is probably caused by reactive bone marrow stimulation, simulating diffuse hematologic neoplastic disease. Erosive intervertebral osteochondrosis with bandlike disk gadolinium enhancement and BME, which is commonly associated with local pain, is the most important differential diagnosis of bacterial spondylitis.

Imaging of the hand: degeneration, impingement and overuse.

Degenerative and overuse diseases as well as impingement syndromes of the hand are illustrated and discussed in this review article. Osteoarthritis of the interphalangeal joints as described by Heberden and Bouchard is a ubiquitous articular disease often associated with synovitis and erosive joint destruction. Osteoarthritis of the trapeziometacarpal joint is classified into four stages for proper indication of operation. Overuse can result in stenosing tenosynovitis around the wrist and in synovitis with or without impingement of the flexor or extensor tendons of the digitis or ruptures of the annular and cruciform pulleys. Although diagnosis of these entities is usually made by history and clinical investigation, ultrasound and MRI can be helpful tools in imaging of these diseases. Scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) are the characteristic degeneration pattern of the wrist and represent the degeneration mechanisms in scapholunate insufficiency and nonunion of the scaphoid. SLAC wrist is a gradual degeneration classified in three stages and found in posttraumatic scapholunate rupture, calcium pyrophosphate dehydrate deposition disease (CPPD), rheumatoid arthritis, neuropathic diseases, trauma, and beta 2-microglobulin associated amyloid deposition. Ulna impaction syndrome is increasingly recognized as a cause of ulnar sided pain and exhibits a characteristic MRI appearance.

Imaging in sports medicine: hand and wrist.

Sports-related injuries of the hand and wrist include lesions of the bones, joints, ligaments, tendons and muscles. In many cases, radiologic imaging procedures are indispensible for the depiction, localization and accurate diagnosis of these lesions. This article reviews the role and potential of current imaging modalities such as conventional radiography, fluoroscopic examinations, arthrography, computed tomography (CT), ultrasound, and magnetic resonance (MR) imaging for the diagnostic work-up of typical osseous and soft tissue injuries in sports medicine.

Angiography of segmental pancreatic transplants.

Arteriography was routinely performed in patients with suspected vascular complications after pancreas transplantation. Dysfunction of the grafts was suggested by 99mTc-DTPA scanning and metabolic tests. Thirty arteriograms obtained in 25 patients were evaluated. Nineteen conventional film angiograms and 11 intraarterial DSA were performed. Five different angiographic patterns were observed: normal vascular anatomy, low-flow phenomenon, arterial or venous thrombosis, and venous neovascularity. On the basis of the angiographic findings, various reasons for graft failure were identified. Recipient venous collaterals or well-functioning grafts without angiographically detectable blood supply were observed in 9 cases, and must be considered to represent neovascularisation by donor and recipient vessels.

[The pathophysiological etiological mechanism of destructive wrist joint arthropathy in pseudogout]. / Der pathophysiologische Entstehungsmechanismus der destruierenden Handgelenksarthropathie bei Pseudogicht.

The pathogenesis of destructive joint lesions of the wrist in pseudogout is explained using the concept of compartments of the radiocarpal joint and bearing in mind the biomechanical situation. The progressive destruction of the joints in the wrist begins with degenerative changes in the radial styloid, then zigzags through the scapho-lunate joint into the medio-carpal joints and ultimately leads to collapse of the carpus. In its final stage there is a characteristic extensive defect in the radial styloid process. Following cartilage degeneration there is subchondral sclerosis, bone destruction, sclerosing cysts and occasionally loose bodies in the joint. Chondrocalcinosis of the triangular cartilage is a common finding which assists in making the diagnosis.

[MRT in dialysis-associated destructive spondylarthropathy of the atlantoaxial region]. / MRT der dialyseassoziierten, destruierenden Spondylarthropathie der Atlantoaxialregion.

Destructive bone and joint diseases in patients on longterm haemodialysis increase in frequency and are often caused by beta 2-microglobulin-related amyloid deposits. Due to the excellent visualisation of amyloid, MRI with T1-weighted and out-of-phase gradient recalled long TR images is the diagnostic modality of choice. 5 patients, 13 to 21 years on haemodialysis, were investigated. In four patients we found involvement of the atlantoaxial region, one patient was asymptomatic, the other three had severe neurological deficiencies.

[The nuclear magnetic tomographic diagnosis of focal lesions of the red bone marrow. The optimization of the acquisition parameters for GE and SE sequences]. / Kernspintomographische Diagnostik fokaler Läsionen des roten Knochenmarks. Optimierung der Akquisitionsparameter für GE- und SE-Sequenzen.

Gradient-echo (GE) imaging with repetition times equivalent to those of T1-weighted spin-echo (SE) sequences and echo times for antiphase (opposed) transverse magnetisation have proved to be sensitive for high contrast imaging of focal lesions of red bone marrow. The sensitivity of antiphase GE sequences is due to the chemical shift between water-bound and fat-bound protons which introduces a tissue parameter that is not accessible by SE sequences. Main advantage of these GE sequences is the low signal intensity of intact red marrow and the high signal intensity of tumours and inflammatory lesions which allows, similar to T2-weighted SE sequences, for positive contrast imaging of lesions. In order to evaluate and to optimise the contrast-to-noise ratio (CNR) for red bone marrow and tumour 200 GE and 40 SE sequences with repetition times (TR) between 100 and 900 ms, echo times (TE) between 14 and 21 ms and flip angles (alpha) between 10 and 90 degrees were studied. CNR was measured and optimized regarding TR, TE, and alpha. The results indicate that opposed GE sequences, relatively independent from TR and alpha, are characterized by a high contrast-to-noise ratio. According to their high sensitivity for lesion detection they are suited to replace T2-weighted SE sequences.

["Inflammatory" disk degeneration. Magnetic resonance tomographic clinical picture]. / Die "entzündliche" Bandscheibendegeneration. Kernspintomographisches Erscheinungsbild.

Disc degeneration, if it appears relatively early, progresses rapidly with inadequate bone compensation for stabilisation of the area, or in the presence of anatomic variation of the vertebrae with short sagittal diameters, there may be tissue proliferation and edema in the bone marrow and vascular granulations within the disc. We demonstrated these changes in 17 patients by means of MRT which shows edema of the bone marrow and contrast enhancement within the disc. All these patients had severe symptoms. There were no significant neurological findings since in general there was no disc prolapse. The MRT characteristics of this condition are described and correlated with the clinical and radiological features. The use of Gd-DTPA and subtractive spin-echo and gradient-echo sequences in the differential diagnosis from infective discitis is discussed.

[Penetrating aortic ulceration: an unusual form of aortic dissection]. / Die penetrierende Aortenulzeration: Eine Sonderform der Aortendissektion.

PURPOSE: The aim was to present clinical findings and imaging criteria for patients with aortic ulcers of the thoracic aorta. METHODS: From 1993 to 1996 computed tomography of patients suffering from acute thoracic pain and suspected pathologies of the aorta were reviewed for penetrating aortic ulcers. Pathoanatomical correlation was done by autopsy in three cases and with intraoperative inspection in two cases. MRI was available in three patients and angiography in 5 patients. RESULTS: 9 patients with aortic ulcers could be identified. The imaging criteria in CT were: 1. Hyperdense wall thickening on unenhanced CT scans (medial haematoma). 2. Displaced intimal calcifications outlining the lumen. 3. Small contrast-filled ulcer. 4. Absence of a contrast-filled false lumen. In 4 of the 9 cases the aorta ascendens was affected. The clinical presentation is that of an elderly patient with acute onset of thoracic pain and generalised atherosclerosis due to hypertension and nicotine abuse. DISCUSSION: Penetrating ulcers with haematoma of the media are a special case of aortic dissection, with different features on unenhanced and enhanced CT scans.

[Infiltration patterns of plasmacytomas in magnetic resonance tomography]. / Infiltrationsmuster des Plasmozytoms in der Magnetresonanztomographie.

PURPOSE: To define the different infiltration patterns in the spine in multiple myeloma, in correlation with histological and clinical findings. Quantitative signal evaluation with contrast media (Gd-DTPA). To compare the results in MRI with X-ray films. MATERIAL AND METHODS: 61 patients with proven multiple myeloma and 50 controls were examined (1.0 Tesla, T1-w SE, opposed phase GE images). RESULTS: Five infiltration patterns with different clinical stages were detected: normal bone marrow (11%) in cases of low interstitial marrow infiltration (biopsy), pure diffuse infiltration (25%), focal involvement (33%), combined diffuse/focal infiltration (23%) and a "salt-and pepper" pattern (8%). In diffuse plasmacytoma the 40% signal intensity increase was modification of diffuse infiltration. MRI proved to be more sensitive than radiography. CONCLUSION: MRI is able to show the type and the extension of bone marrow infiltration in multiple myeloma. Diffuse involvement can be objective with gadopentetate dimeglumine.

[The implantation of elastic metal endoprostheses in tracheal stenosis and tracheomalacia. The initial results with 4 patients]. / Implantation elastischer Metallendoprothesen bei Trachealstenosen und Tracheomalazie. Erste Ergebnisse bei 4 Patienten.

Narrowing of the trachea due to tracheomalacia or compression can lead to life-threatening asphyxia and may require tracheotomy with intubation or endoscopic introduction of a stent. The use of a self-expanding elastic metal prosthesis in 4 patients with airway obstruction has proved a satisfactory alternative to conventional plastic prostheses, both in the acute phase and over a long period of time. After 4 weeks total epithelium cover of the stent could be demonstrated; biopsies after 3 and 4 months showed differentiation into respiratory ciliated epithelium. Patient acceptance was excellent since there was no sensation of a foreign body, retention of secretions or cough. The physical properties of the wall stent made it a suitable mechanical replacement for an unstable or narrowed trachea during the period of observation.

[The percutaneous treatment of surgical and catheter-angiographic vascular complications]. / Perkutane Behandlung chirurgischer und katheterangiographischer Gefässkomplikationen.

PURPOSE: Technical innovations of angioplasty have introduced new therapeutic options in the treatment of symptomatic arteriosclerotic disease. Atherectomy devices, aspiration catheters and vascular endoprostheses can be used not only for angioplasty purpose but also for correction of iatrogenic dissections and thromboembolic complications. MATERIAL AND METHODS: 54 patients with vascular complications after surgical (n = 7) and percutaneous (n = 47) interventions were observed in a 5 years period. The complications included acute dissections in 34 cases, acute thrombosis in 4 cases, distal embolism after angioplasty in 14 cases, and two cases with arterial rupture after balloon dilatation. RESULTS: 34 patients with dissections and 18 patients with acute thrombosis were treated. Stent implantation for repair of vessel dissection was successful in 33 of 34 cases. Percutaneous catheter aspiration in combination with local thrombolysis was successful in 4 cases with local thrombosis. Distal emboli after angioplasty were successfully removed using aspiration catheters in 13 of 14 patients. Vessel rupture after angioplasty was closed with prolonged balloon dilatation in two patients avoiding emergency surgery. CONCLUSION: Using newly developed intravascular technologies such as atherectomy, stents, and catheter aspiration, many iatrogenic complications after vascular surgery or vascular interventions can be treated. These technologies should be available in every radiology department performing angioplasty.

[The nuclear magnetic resonance tomographic differentiation of osteoporotic and tumor-related vertebral fractures. The value of subtractive TR gradient-echo sequences, STIR sequences and Gd-DTPA]. / Kernspintomographische Differenzierung osteoporotisch- und tumorbedingter Wirbelkörperfrakturen. Wertigkeit von subtraktiven Gradientenecho-Sequenzen mit verlängerter Repetitionszeit, STIR-Sequenzen und Gd-DTPA.

42 patients with known malignancy and vertebral compressions underwent MRI. Sagittal T1-weighted spin-echo images pre and post Gd-DTPA, out of phase long TR gradient-echo images (GE) and short T1 inversion recovery images (STIR) were obtained at 1.0 T. The results were confirmed by histology (6/42) or clinical data (28/42) and follow up MRI studies (8/42). In 39 of 42 cases a correct differentiation between osteoporotic and tumorous vertebral compression fractures was possible by quantification and correlation of SE and GE signal intensities. Gd-DTPA did not improve differential diagnosis, since both tumour infiltration and bone marrow oedema in acute compression fracture showed comparable enhancement. STIR-sequences were most sensitive for pathology but unspecific due to a comparable amount of water in tumour tissue and bone marrow oedema. Susceptibility-induced signal reduction in GE images and morphologic criteria proved to be most reliable for differentiation of benign and tumour-related fractures. In the rare cases of single and nearly complete vertebral compressions with complete loss of bone marrow, differentiation with MRI was not possible.