[The ulnocarpal complex : New clinical and radiological considerations]. / Der ulnokarpale Komplex : Neue klinische und radiologische Überlegungen.

CLINICAL ISSUE: The triangular fibrocartilage complex (TFCC) is an anatomically complex structure with high demands on spatial and contrast resolution in imaging. RADIOLOGICAL METHODS: The central, predominantly avascular articular disc can be distinguished from the ligamentous, vascularized periphery. Imaging methods include magnetic resonance imaging (MRI, preferably contrast-enhanced) as well as MR and computed tomography (CT) arthrography. DIAGNOSTIC INNOVATIONS: While high-resolution MRI represents the standard diagnostic tool for the TFCC in general, arthrographic imaging is particularly useful for assessment of the foveal (proximal) lamina of the TFCC. In radiological reporting, the convergence of the TFCC periphery towards the ulnar styloid process and the ulnar fovea must be considered. ACHIEVEMENTS: The Palmer classification is suitable for evaluating lesions of the articular disc, whereas the Atzei classification is superior for lesions of the ulnar TFCC insertions. PRACTICAL RECOMMENDATION: Use of a high-resolution examination technique and anatomy-based image interpretation are important for reliable MRI of the TFCC.

Osteonecrosis of the Upper Extremity: MRI-Based Zonal Patterns and Differential Diagnosis.

Regarding the upper extremity, osteonecrosis can relate to the humeral head and to any carpal bone, most commonly the lunate (Kienböck's disease), scaphoid (Preiser's disease and nonunion), and capitate bone (osteonecrosis of the capitate head). In children and adolescents, osteochondrosis is an important differential diagnosis at the epiphyses. Appropriate imaging of osteonecrosis depends on knowledge about blood supply, biomechanical load, and bone repair mechanisms. Contrast-enhanced MRI (ceMRI) enables the differentiation of up to three mostly band-shaped zones: necrotic tissue (proximal), hypervascular repair tissue (intermediate), and viable bone (distal). To distinguish between necrotic and repair zones, intravenous gadolinium is recommended in MRI. Osteosclerosis and insufficiency fractures in early and intermediate stages as well as osteoarthritis in advanced stages are best depicted using high-resolution CT (HRCT). The combination of HRCT and ceMRI allows for exact classification of osteonecrosis regarding morphology and viability.

[Distal radius fractures : Update on imaging]. / Distale Radiusfrakturen : Update zur Bildgebung.

Distal radius fractures are associated with high individual and socioeconomic relevance. Optimized radiography and computed tomography (CT) imaging are essential for individualized therapy planning. Plain CT imaging with 3D reconstruction and digital removal of the carpus and ulna is helpful for choosing the surgical approach in the presence of intra-articular radius fractures. If the fracture line leads towards the scapholunate compartment, ligamentous injury requiring treatment can be detected or ruled out before surgery with the help of direct CT arthrography (CTA). Acquisition of imaging data and morphometrical analysis must be standardized and reproducible. In the diagnostics of distal radius fractures it is necessary for radiologists and surgeons to use a unified fracture classification.

Imaging for local recurrence of breast cancer.

PURPOSE: Isolated locoregional recurrence of breast cancer (ILRR) and contralateral breast cancer (CBC) affect up to 20% of all breast cancer (BC) patients in the first 20 years after primary diagnosis. Treatment options comprise surgical interventions and further systemic therapies depending on the histological subtype. Patients with hereditary breast or ovarian cancer (HBOC) undergo MRI, mammography, and ultrasound in the aftercare of BC, while non-HBOC (nHBOC) patients do not regularly receive MRI. Since early detection is crucial for morbidity and mortality, the evaluation and constant improvement of imaging methods of the breast is necessary. METHODS: We retrospectively analyzed the data of 1499 former BC patients that received imaging of the breast at a tertiary-care university hospital between 2015 and 2020. The analysis comprised various patient characteristics, such as breast density, age, tumor size and subtype, and their influence on BC detection rates by the different imaging methods. RESULTS: Within the patient sample, 176 individuals (11.7% of former BC patients) were diagnosed with either ILRR or CBC. CBC was observed in 32.4% of patients, while both ILRR and secondary breast cancer occurred in 20.5% and 23.9% of all patients. Sensitivity of MRI, mammography, and ultrasound for recurrent malignancy was 97.9%, 66.3%, and 67.8%, respectively. ILRR and CBC detection rates were similar for patients with and without HBOC history. Lower breast density and larger tumor size increased the detection rates of all imaging modalities. CONCLUSION: In breast cancer survivors, MRI might improve the early detection of ILRR and CBC in both HBOC and nHBOC patients.

Noise-optimized virtual monoenergetic reconstructions of dual-energy CT angiographies improve assessability of the lower leg arterial segments in peripheral arterial occlusive disease.

INTRODUCTION: The aim of this study was to evaluate the influence of a noise optimized virtual monoenergetic reconstruction algorithm (VMI+) on the image quality and assessability of dual energy (DE) computed tomography angiography (CTA) of the lower extremity runoff. METHODS: A total of 118 lower extremity runoff CTA performed on a 3rd generation DE-CT scanner in 109 patients (54 females; 75.6 ± 9.5 years) were included in this retrospective study. Axial image stacks were reconstructed with a standard 120 kV setting and VMI+ of different keV levels. Objective image quality criteria (contrast attenuation, signal-to-noise [SNR] and contrast-to-noise ratio [CNR]) were measured. Two radiologists evaluated subjective image quality regarding intraluminal attenuation and image noise using a 5-point Likert scale. Diagnostic accuracy for significant stenosis (>75%) and vessel occlusion was assessed for 120 kV and 50 keV VMI+ images rated by two radiologists. In all patients, a digital subtraction angiography (DSA) rated by on board-certified radiologist served as the standard of reference. RESULTS: Intraluminal attenuation was highest in 40/50 keV VMI+ while SNR were similar to 120 kV images. In subjective assessment, intraluminal contrast of 50 keV images was deemed superior compared to 120 kV despite higher image noise. Sensitivity, specificity, and accuracy for detection of a vessel occlusion were similar in 50 keV VMI+ compared to 120 kV (70%/92%/84%; 70%/91%/83%; p < 0.001) but 13 of 118 (11%) lower leg runoffs were only assessable with 50 keV VMI+. CONCLUSION: VMI+ reconstructions improve assessability of DE-CTA by increased luminal attenuation with consistent image noise, also allowing the evaluation of lower leg arterial segments inassessable with standard reconstructions. IMPLICATIONS FOR PRACTICE: Providing higher intraluminal attenuation and similar image noise compared with conventional reconstructions, 50 keV VMI+ may be appropriate for routine evaluation of DE-CTA.

Potential of employing a quantum iterative reconstruction algorithm for ultra-high-resolution photon-counting detector CT of the hip.

INTRODUCTION: This study investigated the image quality of a new quantum iterative reconstruction algorithm (QIR) for high resolution photon-counting CT of the hip. METHODS: Using a first-generation photon-counting CT scanner, five cadaveric specimens were examined with ultra-high-resolution protocols matched for radiation dose. Images were post-processed with a sharp convolution kernel and five different strength levels of iterative reconstruction (QIR 0 - QIR 4). Subjective image quality was rated independently by three radiologists on a five-point scale. Intraclass correlation coefficients (ICC) were computed for assessing interrater agreement. Objective image quality was evaluated by means of contrast-to-noise-ratios (CNR) in bone and muscle tissue. RESULTS: For osseous tissue, subjective image quality was rated best for QIR 2 reformatting (median 5 [interquartile range 5-5]). Contrarily, for soft tissue, QIR 4 received the highest ratings among compared strength levels (3 [3-4]). Both ICCbone (0.805; 95% confidence interval 0.711-0.877; p < 0.001) and ICCmuscle (0.885; 0.824-0.929; p < 0.001) suggested good interrater agreement. CNR in bone and muscle tissue increased with ascending strength levels of iterative reconstruction with the highest results recorded for QIR 4 (CNRbone 29.43 ± 2.61; CNRmuscle 8.09 ± 0.77) and lowest results without QIR (CNRbone 3.90 ± 0.29; CNRmuscle 1.07 ± 0.07) (all p < 0.001). CONCLUSION: Reconstructing photon-counting CT data with an intermediate QIR strength level appears optimal for assessment of osseous tissue, whereas soft tissue analysis benefitted from applying the highest strength level available. IMPLICATIONS FOR PRACTICE: Quantum iterative reconstruction technique can enhance image quality by significantly reducing noise and improving CNR in ultra-high resolution CT imaging of the hip.

Metal artefact reduction in low-dose computed tomography: Benefits of tin prefiltration versus postprocessing of dual-energy datasets over conventional CT imaging.

INTRODUCTION: The purpose of this study was to determine the potential for metal artefact reduction in low-dose multidetector CT as these pose a frequent challenge in clinical routine. Investigations focused on whether spectral shaping via tin prefiltration, virtual monoenergetic imaging or virtual blend imaging (VBI) offers superior image quality in comparison with conventional CT imaging. METHODS: Using a third-generation dual-source CT scanner, two cadaveric specimens with different metal implants (dental, cervical spine, hip, knee) were examined with acquisition protocols matched for radiation dose with regards to tube voltage and current. In order to allow for precise comparison, and due to the relatively short scan lengths, automatic tube current modulation was disabled. Specifically, the following scan protocals were examined: conventional CT protocols (100/120 kVp), tin prefiltration (Sn 100/Sn 150 kVp), VBI and virtual monoenergetic imaging (VME 100/120/150 keV). Mean attenuation and image noise were measured in hyperdense and hypodense artefacts, in artefact-impaired and artefact-free soft tissue. Subjective image quality was rated independently by three radiologists. RESULTS: Objectively, Sn 150 kVp allowed for the best reduction of hyperdense streak artefacts (p < 0.001), while VME 150 keV and Sn 150 kVp protocols facilitated equally good reduction of hypodense artefacts (p = 0.173). Artefact-impaired soft tissue attenuation was lowest in Sn 150 kVp protocols (p ≤ 0.011), whereas all VME showed significantly less image noise compared to conventional or tin-filtered protocols (p ≤ 0.001). Subjective assessment favoured Sn 150 kVp regarding hyperdense streak artefacts and delineation of cortical bone (p ≤ 0.005). The intraclass correlation coefficient was 0.776 (95% confidence interval: 0.712-0.831; p < 0.001) indicating good interrater reliability. CONCLUSION: In the presence of metal implants in our cadaveric study, tin prefiltration with 150 kVp offers superior artefact reduction for low-dose CT imaging of osseous tissue compared with virtual monoenergetic images of dual-energy datasets. The delineation of cortical boundaries seems to benefit particularly from spectral shaping. IMPLICATIONS FOR PRACTICE: Low-dose CT imaging of osseous tissue in combination with tin prefiltration allows for superior metal artefact reduction when compared to virtual monoenergetic images of dual-energy datasets. Employing this technique ought to be considered in daily routine when metal implants are present within the scan volume as findings suggest it allows for radiation dose reduction and facilitates diagnosis relevant to further treatment.

The effect of tin prefiltration on extremity cone-beam CT imaging with a twin robotic X-ray system.

INTRODUCTION: While tin prefiltration is established in various CT applications, its value in extremity cone-beam CT relative to optimized spectra has not been thoroughly assessed thus far. This study aims to investigate the effect of tin filters in extremity cone-beam CT with a twin-robotic X-ray system. METHODS: Wrist, elbow and ankle joints of two cadaveric specimens were examined in a laboratory setup with different combinations of prefiltration (copper, tin), tube voltage and current-time product. Image quality was assessed subjectively by five radiologists with Fleiss' kappa being computed to measure interrater agreement. To provide a semiquantitative criterion for image quality, contrast-to-noise ratios (CNR) were compared for standardized regions of interest. Volume CT dose indices were calculated for a 16 cm polymethylmethacrylate phantom. RESULTS: Radiation dose ranged from 17.4 mGy in the clinical standard protocol without tin filter to as low as 0.7 mGy with tin prefiltration. Image quality ratings and CNR for tin-filtered scans with 100 kV were lower than for 80 kV studies with copper prefiltration despite higher dose (11.2 and 5.6 vs. 4.5 mGy; p < 0.001). No difference was ascertained between 100 kV scans with tin filtration and 60 kV copper-filtered scans with 75% dose reduction (subjective: p = 0.101; CNR: p = 0.706). Fleiss' kappa of 0.597 (95% confidence interval 0.567-0.626; p < 0.001) indicated moderate interrater agreement. CONCLUSION: Considerable dose reduction is feasible with tin prefiltration, however, the twin-robotic X-ray system's low-dose potential for extremity 3D imaging is maximized with a dedicated low-kilovolt scan protocol in situations without extensive beam-hardening artifacts. IMPLICATIONS FOR PRACTICE: Low-kilovolt imaging with copper prefiltration provides a superior trade-off between dose reduction and image quality compared to tin-filtered cone-beam CT scan protocols with higher tube voltage.

A fast 3D-imaging technique for performing dynamic Gd-enhanced MRI of breast lesions.

The characterization of breast lesions by their Gd-enhancement profiles has been proposed as a method for differentiating benign from malignant breast lesions. The limitations of dynamic contrast enhanced 2D imaging of the breast are the low number of slices that can be acquired, and the need to know the location of the lesion a priori to correctly select the noncontiguous 2D slice locations. These problems are exacerbated when multi-focal disease is present but not anticipated. Standard fast 3D gradient-echo imaging has a variable delay between successive acquisitions. We have developed a fast 3D gradient-echo imaging technique for dynamic Gd-DTPA enhanced breast imaging which obtains multiple 3D image sets of 32 contiguous images at 44 s intervals without an interscan delay time. This rapid 3D imaging technique achieves good temporal resolution and reduces patient motion between pre- and postcontrast images while covering a much larger portion of the breast and eliminating the need for a priori knowledge concerning the location of the lesion(s) when performing Gd-enhanced dynamic MR imaging.

Torsion of a hepatic lobe in the neonate--ultrasound findings.

We report a case of projectile vomiting in an infant, secondary to torsion of an accessory lobe of the liver, imaged by ultrasound.