Prospective evaluation of two different injection techniques for MR arthrography of the hip

The aim of the study was to evaluate prospectively the technical feasibility and discomfort of two different injection techniques for MR arthrography of the hip. Sixty-one consecutive patients undergoing MR arthrography of the hip (68 hips) were randomly injected either at the femoral head (36 hips) or the femoral neck (32 hips). The patients rated discomfort during and 0–72 h after arthrography using a visual analogue scale (VAS, 0=did not feel anything, 100=unbearable). The volume injected, the distance between the needle tract and the neurovascular bundle, the duration of the procedure and the extra-articular contrast leakage were measured. No significant differences were found for the volume injected, the distance between the needle tract and the neurovascular bundle, or the procedure duration. Volume of extra-articular contrast leakage was statistically significantly different (head 1±2 cm³, neck 3±5 cm³, P=0.024). The VAS score for needle advancement was significantly different (head 25±20, neck 19±23, P=0.031). No significant differences were found for the VAS score regarding delayed discomfort. Before the examination the arthrography-related discomfort was overestimated by 74% (50/68), correctly anticipated by 22% (15/68) and underestimated by 4% (3/68) of the patients. MR-related discomfort was overestimated by 32% (22/68), correctly anticipated by 57% (39/68) and underestimated by 10% (7/68) of the patients. Both hip puncture techniques were well tolerated. The neck injection technique produced less discomfort and was associated with greater extra-articular contrast leakage.     

The value of T1-weighted images in the differentiation between MS,white matter lesions,and subcortical arteriosclerotic encephalopathy (SAE)

Summary The aim of the study was to define reliable criteria for the differentiation of MR imaging between patients with MS and with vascular white matter lesions/SAE. We examined 35 patients with proven MS according to the Poser criteria and 35 patients with other white matter lesions and/or SAE. The result is that with MR a differentiation can be achieved provided that T1-weighted spin-echo sequences are included and the different pattern of distribution is considered. MS plaques are predominantly located in the subependymal region, vascular white matter lesions are mainly located in the water-shed of the superficial middle cerebral branches and the deep perforating long medullary vessels in the centrum semiovale. Infratentorial lesions are more often seen in MS. Confluence at the lateral ventricles is frequently accompanied by confluent abnormalities around the third ventricle, Sylvian aqueduct, and fourth ventricle, which is uncommon in SAE. In MS many lesions visible on T2-weighted images have a cellular or intracellular composition that renders them visible also on T1-weighted ones as regions with low signal intensity and more or less distinct boundary. Vascular white matter lesions and SAE mainly represent demyelination and can there-fore be seen on T2-weighted images, but corresponding low signal intensity lesions on T1-weighted images are uncommon. In some exceptions there are such lesions with low signal representing lacunar infarcts or widened Virchow-Robin-spaces.     

Hip arthropathy in ochronosis: Anatomical and radiological study

Anatomical and radiological studies of four cases of ochronotic arthropathy of the hip were based on the examination of a total of six surgically removed femoral heads. One of these had undergone a surgical biopsy 10 years previously.The impregnation of the articular cartilage by the ochronotic pigment causes it to break into small fragments in the weight-bearing zone. This results in a similar osteoarthrotic remodelling to that commonly attributed to the histologically different degenerative chondropathy.The labelling of the cartilage in ochronotic arthropathies offers an opportunity for better understanding of the main nonspecific components of osteoarthrotic remodelling. An anatomico-pathological approach explains why their radiological images in the hip may simulate those of rheumatoid arthritis.     

The crescent sign: dissociation of the polyethylene liner from a modular acetabular component in total hip arthroplasty

Objective To study whether there was a common pattern of clinical symptoms, signs and radiographic features for the dissociation of the polyethylene liner from an acetabular component and to postulate reasons for these features.Design and patients Retrospective study of notes and radiographs of cases of revision hip arthroplasty for polyethylene liner dissociation of the cementless Harris–Galante I porous-coated acetabular component (Zimmer Inc, Warsaw, IN) at the Avon Orthopaedic Centre, Bristol, UK and St. Marys Hospital, Bristol, UK between 1995 and 2004. Patients were contacted to confirm preoperative symptoms.Results Nine cases of late polyethylene liner dissociation of this prosthesis have been revised in these institutions. All patients presented with a reduction in mobility, groin pain and limp. Eight patients reported an audible noise on hip movement. In all cases, radiographs showed radiolucency medial to the femoral neck in association with an eccentrically placed femoral head showing contact with the acetabular metal shell, which we have termed the crescent sign.Conclusions There is a typical clinical presentation in this study. The diagnosis can be made from a single anteroposterior pelvic radiograph without the need for previous films for comparison, or the need for arthrography. Clinicians should look specifically for the crescent sign when an eccentrically placed femoral head has been noted, in order to differentiate the more unusual diagnosis of dissociation from that of polyethylene wear. Early revision surgery can prevent damage to the femoral head and metal acetabular shell, thus reducing the complexity of revision surgery.     

Pseudopathologic fracture of the femoral neck

We have seen two cases of traumatic subcapital fractures of the femoral neck which resembled pathologic fractures on plain radiography. We have named this entity pseudopathologic fracture of the femoral neck and offer suggestions for why it occurs.     

γ-Glutamyltransferase test as a new tool for identification of seminal stains

Summary A simple qualitative method for identification of seminal stains based on a high activity of -glutamyltransferase (-GTP) in human semen is described. It employs the release of -naphthylamine from N--glutamyl--naphthylamide by the -GTP action; -naphthylamine couples with Fast Garnet GBC salt to produce a strong brownish-red color. The data on its simplicity, specificity, and stability show that the present method is suitable for medicolegal examination of seminal stains as a preliminary test.     

Magnetic resonance imaging and histopathology of cerebral gliomas

Summary The correlation of magnetic resonance imaging (MRI) with histopathological findings was analysed in 26 patients with untreated cerebral gliomas. In low-grade gliomas, T2-weighted images demonstrated relatively homogeneous high-intensity lesions involving both the grey and the white matter. In high-grade gliomas, especially grade IV, T2-weighted images demonstrated prominent heterogeneity in signal intensity, which consisted of a hyperintense core, less hyperintense or normal intensity rim and surrounding finger-like areas of high intensity. Marked and irregular contrast enhancement was evident in all but one case of these high-grade gliomas in which gadolinium-DTPA was used. Histological examination revealed tumour cells extending as far as the borders of the high-intensity areas shown on T2-weighted images in both high-and low-grade gliomas, but in 5 of 8 low-grade and 4 of 18 high-grade gliomas, isolated tumour cells extended beyond the hyperintense areas shown on T2-weighted images.     

Unusual MR manifestations of neurocysticercosis

Summary MR and CT features of neurocysticercosis are variable and depend fundametally on the stage in evolution of the infection, location, number and size of the worm. The authors retrospectively evaluated MR images obtained on a 2.0T superconducting unit in 22 neurocysticercosis patients and observed various MR features including some new findings. A variety of MR findings are presented with special reference to six case reports. The features include: (1) a large simple cyst containing both internal septations and a scolex; (2) suprasellar racemose cysts mimicking other cysts, (3) a fourth ventricular cyst readily depicted by aid of CSF flow-void in the sagittal plane; (4) degenerating cysts showing white target appearance; (5) granulomatous lesions having a black target appearance; and (6) a meningitic form showing Gd-DTPA enhancement of basal cisterns and of a subacute infarct.     

SLAP lesions of the glenoid labrum diagnosed with MR imaging

Tears of the superior portion of the glenoid labrum in patients without shoulder instability have recently been described. These tears, which include the anchor of the biceps tendon to the labrum, have been labeled SLAP lesions (superior /abrum anterior to posterior). This study was performed to determine the magnetic resonance (MR) findings in patients with SLAP lesions. Retrospective review of the shoulder arthroscopy reports on patients who underwent MR imaging using a 1.5-T unit and subsequent arthroscopy by a single surgeon identified six patients with SLAP lesions (average age 36 years, range 17–65 years). MR images demonstrated atypical morphology indicative of tear in the superior portion of the labrum in four of the six patients, but only one tear had been identified preoperatively. Radiologists interpreting MR images of the shoulder should be aware of the MR findings of SLAP lesions as these tears can be a significant cause of patient disability and are difficult to diagnose clinically.     

Positron CT imaging of an impending stroke

Summary We present PET findings of a case of a transient ischemic attack which later progressed to cerebral infarction. Cerebral blood flow at the stroke focus in the right parietal cortex measured after a TIA attack and before stroke was as low as 24 ml/100 g/min with some increase in oxygen extraction fraction and blood volume. The condition was compatible with misery perfusion. This case may be an example suggestive that the misery perfusion sign is a warning of impending stroke and its poor prognosis if left without appropriate treatments.     

“Menigeal sign”: a characteristic finding of meningiomas on contrast-enhanced MR images

Summary In meningiomas, a flat, contrast-enhancing, probably dural structure adjacent to the tumor can occasionally be observed on Gadolinium-DTPA enhanced MR images. This so called meningeal sign was evaluated with respect to the differential diagnosis of meningiomas in MR imaging. The study included 29 patients with intracranial meningiomas and 24 patients with non-meningeal brain tumors. In all meningiomas, MR studies included T2-weighted as well as unenhanced and Gadolinium-DTPA-enhanced T1-weighted images. In all nonmeningeal tumors, Gd-DTPA-enhanced MR images were available. All images were evaluated with respect to the presence of the meningeal sign. In meningiomas, a meningeal sign was seen in 15/29 cases on Gadolinium-DTPA-enhanced images. No abnormalities corresponding to the areas of contrast enhancement were found on unenhanced T2- and T1-weighted MR images. In nonmeningeal tumors only 2/24 cases showed a meningeal sign. In conclusion, with a sensitivity of 52% and a specificity of 92%, the demonstration of the meningeal sign improved the differential diagnosis of intracranial meningiomas in contrast-enhanced MR imaging.     

The immunohistochemical localization of alpha1-antichymotrypsin and fibronectin and its meaning for the determination of the vitality of human skin wounds

Summary A total of 39 vital human skin wounds (20 cases with short survival times ranging from a few seconds to approximately 30 min and 19 cases with wound ages between 50 min and 13 days) were investigated. Alpha,-antichymotrypsin (A₁-ACT) was visualized by immunohistochemistry. Additionally, fibronectin was localized in 13 of these wounds (8 cases with short and 5 cases with longer survival times). Furthermore, 13 postmortem lesions (stab wounds) were removed from corpses approximately 4h after infliction and analyzed for A₁-ACT and fibronectin. The vital reaction previously described for A₁-ACT in form of a band-shaped staining pattern at the wound edges was observed in both vital wounds and in most postmortem lesions. A similar reaction was also obtained for fibronectin in wounds inflicted after death, but could be unambiguously distinguished from vital fibronectin staining by morphological criteria. Therefore, it seems questionable that the vitality of skin wounds can be determined by the immunohistochemical detection of A₁-ACT and probably other proteinase inhibitors. The meaning of the localization of fibronectin for the determination of the vitality of human skin wounds with a survival time of at least a few minutes could be confirmed.This study was supported by a grant from the Deutsche Forschungsgemeinschaft (grant No. Ei 209/3-1) and by a grant from the Friedrich-Baur-Stiftung, University of Munich, Germany     

Technical parameters influencing the severity of injury of front-seat,belt-protected car passengers on the impact side in car-to-car side collisions with the main impact between the front and rear seats (B-pillars)

Summary Authentic car-to-car side collisions (n = 30) with the main impact area at the B-pillar were analyzed to find technical parameters corresponding with the injury severities of the front seat, belt-protected car passengers on the impact side. EES (Energy Equivalent Speed) and Av (delta v, change in velocity) were highly significant predictors of the severity of thoracic and abdominal injuries and total injury severity coded according to the Abbreviated Injury Scale (AIS). At an EES or v 40 km/h all front-seat car passengers on the impact side sustained a total injury severity of Maximum AIS (MAIS) 4 and died. Although a passenger could survive the crash without injury to one or more body regions up to the highest EES- and Av-values, at EES or v 40 km/h fatal injuries were sustained in at least one body region. At an EES 35 km/h or a Av 15 km/h no front-seat car passenger on the impact side remained uninjured.     

Ossification and pseudoepiphysis formation in the “nonepiphyseal” end of bones of the hands and feet

Metacarpals, metatarsals, and phalanges were studied to assess the developmental morphology of secondary ossification in the nonepiphyseal ends of these bones as well as the formation of the pseudoepiphysis as an epiphyseal ossification variant. Both direct ossification extension from the metaphysis into the epiphysis and pseudoepiphysis formation preceded, and continued to be more mature than, formation and expansion of the classic epiphyseal (secondary) ossification center at the opposite end of each specific bone. Direct metaphyseal to epiphyseal ossification usually started centrally and expanded hemispherically, replacing both physeal and epiphyseal cartilage simultaneously. In contrast, when remnants of physis were retained, while juxtaposed epiphyseal cartilage was replaced, a pseudoepiphysis formed. There were three basic patterns of pseudoepiphysis formation. First, a central osseous bridge extended from the metaphysis across the physis into the epiphysis and subsequently expanded to create a mushroom-like osseous structure. In the second pattern a peripheral osseous bridge formed, creating either an osseous ring or an eccentric bridge between the metaphysis and the epiphysis. In the third pattern, multiple bridging occurred. In each situation the associated remnant physis lacked typical cell columns and was incapable of significantly contributing to the postnatal longitudinal growth of the involved bone. Pseudoepiphyses were well formed by 4–5 years and coalesced with the rest of the bone months of years before skeletal maturation was attained at the opposite epiphyseal end, which ossified in the typical pattern (i.e., formation of a secondary center de novo completely within the cartilaginous epiphysis). This process may also affect the development and appearance of ossification within the longitudinal epiphyseal bracket (delta phalanx).     

Methoden zur Bestimmung der mechanischen Eigenschaften der menschlichen Leichenhaut

Zusammenfassung Für die mechanischen Eigenschaften der menschlichen Haut sind die Kollagenfasern des Coriums ausschlaggebend. Sie bilden im ungedehnten Zustand ein statistisch ungeordnetes Netzwerk, das unter dem Einflu einer dehnenden Kraft parallel geordnet wird. Die einzelne Kollagenfaser ist sehr fest und gehorcht dem Hookschen Gesetz.Versuche an der gesamten Haut ergaben, da bei konstantem Dehnungszustand die Kraft mit dem Logarithmus der Versuchsdauer abnimmt. Die Abhängigkeit der Kraft von der Dehnung wird in charakteristischen Kurven dargestellt, aus denen folgt, da die Haut dem Hookschen Gesetz nicht gehorcht. Als kennzeichnende Megröen für die mechanischen Eigenschaften der Haut bieten sich die Zugfestigkeit und die Elastizitätsgröe an, weil sie von der Dehnungsgeschwindigkeit unabhängig sind bzw. von vorhergehenden Dehnungen in gesetzmäiger Weise abhängen.Ein Modell erklärt die experimentellen Ergebnisse; es ist eine Aussage über die Anzahl der an der Dehnung beteiligten Fasern möglich.Anschlieend wird die Abhängigkeit der Zugfestigkeit und der Elastizitätsgröe von verschiedenen Vorbedingungen untersucht (Breite der Hautmestreifen, Entnahmestelle, Hautalter, Flüssigkeitsgehalt und Temperaturvorbehandlung).

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Summary For the mechanical properties of human skin the collagen fibres of the Corium are decisive. In an unextended state they form a statistically unordered network, which is parallelly ordered under the influence of an extending stress. The single collagen fibre is very resistant and reacts under the control of Hooke's law.Experiments with the complete skin had the result, that in a constant state of strain the stress diminishes according to the logarithmus of the duration of the experiment. The relationship between the stress and the strain gives characteristic curves which prove, that the skin is not controlled by Hooke's law. Tensile strength and magnitude of elasticity are utilized as characterizing sizes of measuring for the properties of skin, because they are invariant with respect to rate of strain and legally depend on preceding extensions.A pattern explains the experimental results. It is possible to make a statement about the quantity of fibres, involved in the strain.Then it has been examined, how tensile strength and magnitude of elasticity depend on various conditions (breadth of the stripes of skin, place of excision, time between death and experiment, percentage of liquid, preceding treatment with different temperatures).

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Die vorliegende Arbeit wurde mit Mitteln der Deutschen Forschungsgemeinschaft durchgeführt, wofür ihr der beste Dank gesagt werden soll.Für die Anregung zu dieser Arbeit danke ich Herrn Prof. Dr.Gg. Schmidt und Herrn Prof. Dr. Dr. E.Weinig; Herrn Prof. Dr. E.Mollwo, Direktor des Instituts für Angewandte Physik der Universität Erlangen-Nürnberg, sage ich meinen herzlichen Dank für die ständig gewährte wertvolle Hilfe und Beratung bei der Durchführung der Arbeit.Ferner danke ich Herrn Dr. W.Becker (Nürnberg) und meinem Vater, Herrn Dr. W.Zink, für viele Ratschläge. Schlielich sage ich Fräulein Dr. E.Wagner und Herrn Oberpräparator O.Opitz meinen Dank für die Hilfe bei den Experimenten.     

Early enzyme changes in skin wounds demonstrated by isoelectric focusing in polyacrylamide gel

Summary Esterase patterns in vital skin wound extracts were observed and compared to those seen in normal skin. Employing the relatively simple method of isoelectric focusing in polyacrylamide gel, it was demonstrated that three, consecutively appearing, characteristic changes were visible in the esterase zymograms of vital (pre-mortally) injured skin as compared with skin which was uninjured or post-mortally damaged. One of these characteristics (characteristic a), since it is found only in wound reactions and not in uninjured skin, may represent an enzyme specifically produced during the wound reaction process. All three features normally appeared within 30 min of trauma and the first change within 5 min, even though it had been generally assumed that vital reactions, i.e. wound reactions, could be demonstrated only after a longer period of time. It was possible therefore to determine victim survival time and distinguish between pre- and post-mortal wounds. Also the isoelectric focusing of enzymes apparently gives a more efficient pattern band separation than previous methods.

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Zusammenfassung Durch isoelektrische Fokussierung der Extrakte aus vital verletzter Haut wurden die -Naphthylacetat-spaltenden Enzyme aufgetrennt und mit gleichartig hergestellten Extrakten unverletzter Haut desselben Menschen verglichen. Es konnten 3 nacheinander auftretende Merkmale im Esterasemuster der verletzten Haut festgestellt werden. Die mit a, b und c bezeichneten Unterschiede im Esterasemuster sind für die frühen Wundreaktionen kennzeichnend. Das Merkmal a ist eine nur in vitalen Hautwunden nachweisbare Esterase-Fraktion, die innerhalb 5 min nach der Wundsetzung auftritt. Die Merkmale b und c erscheinen nach dem Merkmal a innerhalb 30 min nach der Verletzung. Der Nachweis von a, b, c in einer Wunde erlaubt eine Beurteilung der Überlebenszeit und ermöglicht außerdem eine Unterscheidung von vitalen und postmortalen Wunden. Die isoelektrische Fokussierung von Enzymen scheint leistungsfähiger zu sein als die bisher zur Kennzeichnung von Wundenzymen angewandten histoenzymatischen und elektrophoretischen Methoden.

     

ROC analysis in radioimmunoassay: An application to the interpretation of thyroglobulin measurement in the follow-up of thyroid carcinoma

This study is an application of the ROC technique to the determination of threshold values (TV) for the interpretation of serum thyroglobulin (Tg) measurements in the follow-up of differentiated thyroid cancer. Serum Tg was assayed using the Henning kit in 1466 samples from 245 individuals. A local or distant recurrence was assessed by clinical examination, radiological and scintigraphic investigations, and was present in 23 patients. The measurements were divided into four groups: 1) measurements performed less than 6 months after thyroidectomy; 2) measurements performed more than 6 months after thyroidectomy; 3) measurements performed during the suppression of pituitary secretion; 4) measurements performed during withdrawal of the substitutive therapy. An ROC curve was calculated for each group and for each curve three TVs were determined: TV1, TV2, and TV3 corresponding to a high sensitivity, a high specificity and a high sum of sensitivity and specificity respectively. TV1 is 3.12 g/l in the four groups. TV2 is 44 g/l, 19 g/l and 30 g/l, in the first, second, third and fourth groups respectively. TV3 is 35 g/l in the first group, 3.12 g/l in both the second and third groups and 30 g/l in the fourth group. When the classical method allows the determination of only one threshold value, the ROC technique allows us to determine threshold values adapted to both the patient clinical status and the chosen sensitivity or specificity.     

The “dural tail” adjacent to meningiomas studied by dynamic contrast-enhanced MRI: a comparison with histopathology

We examined 32 patients with intracranial tumors (17 meningiomas, 8 neuromas, 7 pituitary adenomas) by conventional and dynamic contrast-enhanced MRI. Our aim was to clarify whether the pathological dural contrast enhancement adjacent to meningiomas (the dural tail) is specific to meningiomas and, more important, whether it represents neoplastic dural infiltration or hypervascularization as a tumor accompanying reaction. A dural tail was found in 9 of 17 meningiomas. None of the other extra-axial tumours (neuromas, pituitary adenomas) showed comparable dural enhancement. Dynamic examinations with an ultrafast single slice imaging technique (snapshot-FLASH) after a bolus injection of contrast medium showed a dural tail in seven out of these nine meningiomas, while in two cases the dural tail turned out to be a cortical vein with a characteristic dynamic contrast enhancement pattern. In the dynamic study all seven dural tails were found to have earlier, steeper contrast enhancement than the corresponding tumours. All the tumours and part of the adjacent dura mater in four of the seven meningiomas with dural enhancement were examined histopathologically. In none of these four cases was neoplastic tissue found more than 2 mm away from the main tumour. The results strongly support the suggestion that the dural tail adjacent to meningiomas represents a hypervascular, non-neoplastic dural reaction.     

“Fingerprints” of vertebral trauma—a unifying concept based on mechanisms

Vertebral fractures, like fractures in the peripheral skeleton, occur, in predictable and reproducible patterns that are related to the kind of force applied to the affected bone. The same force applied to the cervical, thoracic, or lumbar column will result in injuries which appear quite similar. A review of 621 injuries to the vertebral column revealed that there are basically four mechanisms of injury: flexion, extension, shearing, and torque (rotation). These injuries may occur by themselves or in combination with one another. The severity and extent of damage produced by any mechanisms is dependent upon the incident force, the position of the patient at the time of injury, and the velocity of the patient. Thus, there is a pattern of recognizable signs which span the spectrum from mild soft tissue damage to severe skeletal and ligamentous disruption. These patterns are termed the fingerprints of the injury, and this presentation illustrates the four basic types of vertebral injury producing those fingerprints.     

Classification of brain compartments and head injury lesions by neural networks applied to MRI

An automatic, neural network-based approach was applied to segment normal brain compartments and lesions on MR images. Two supervised networks, backpropagation (BPN) and counterpropagation, and two unsupervised networks, Kohonen learning vector quantizer and analog adaptive resonance theory, were trained on registered T2-weighted and proton density images. The classes of interest were background, gray matter, white matter, cerebrospinal fluid, macrocystic encephalomalacia, gliosis, and unknown. A comprehensive feature vector was chosen to discriminate these classes. The BPN combined with feature conditioning, multiple discriminant analysis followed by Hotelling transform, produced the most accurate and consistent classification results. Classifications of normal brain compartments were generally in agreement with expert interpretation of the images. Macrocystic encephalomalacia and gliosis were recognized and, except around the periphery, classified in agreement with the clinician's report used to train the neural network.