Diagnose der arrhythmogenen rechtsventrikulären Kardiomyopathie

In 2003 a 16-year-old boy died unexpectedly and the cause of death was determined as cardiomyopathy by the autopsy. A more precise specification of the cardiomyopathy was requested by the relatives 4 years later in particular with respect to the possible presence of an arrhythmogenic right ventricular cardiomyopathy (ARVCM) which mainly has an autosomal dominant inheritance. To diagnose an ARVCM standardized criteria have been developed based on structural, histological, electrocardigraphic and arrhythmogenic factors as well as a positive family anamnesis. At the time of the postmortem diagnostics only structural and histological criteria were available. For the histological verification an imaging analytic procedure described by Angelini et al. in 1993 was used for the quantitative evaluation of the fatty tissue and connective tissue in the myocardium. This procedure was adapted to modern technology standards so that an image analysis could be performed with a customary personal computer. Digital microphotographs of Sudan red and Elastica-van-Gieson stained slices with a 400x magnification were used. These images were processed by means of computer-aided image analysis and the respective areas of fatty tissue and connective tissue were determined. Arrhythmogenic right ventricular cardiomyopathy could be excluded by the investigations, however, an idiopathic dilated cardiomyopathy (DCM) could be diagnosed. The relatives of the deceased were recommended to undertake further physical and genetic examinations.     

Universitätskliniken als Zentren radiologischer Leistungsallianzen im ambulanten und stationären Sektor

Problem. Health care delivery in Germany has to face severe challenges that will lead to a closer integration of services for in- and out-patients. University hospitals play an important role due to their activities in research, education and health care delivery. They are requested to promote and evaluate new means and ways for health care delivery. Methods. The Institute of Clinical Radiology at the University Hospital of the Ludwig-Maximilians-University started teleradiological services for hospitals and general practices in January 1999 in the framework of the “Imaging services – teleradiological center of excellence”. Legal, technical and organizational prerequisites were analyzed. Results. Networks between university hospitals and general practices are not likely to solve all future problems. They will, however, increase the availability of the knowledge of experts even in rural areas and contribute to a quality ensured health care at the patients home. Future developments may lead to international co-operations and such services may be available to patients abroad. Conclusion. Legal, technical and organizational obstacles have to be overcome to create a framework for high quality telemedical applications. University hospitals will play an important role in promoting and evaluating teleradiological services.     

Aktuelle Entwicklungen in der vaskulären Sonographie

Ultrasound plays a central role in the diagnostic imaging of venous and arterial vessels, especially for the assessment or exclusion of arteriosclerotic vessel obstructions as well as venous or arterial thrombosis. Due to its excellent patient acceptance and its broad availability, ultrasound is considered the standard method of choice for vascular imaging. New techniques and methods have greatly enhanced its diagnostic accuracy, the most notable of which are the B-flow technique, a variant of Doppler signal read-out for reduction of artifacts in duplex sonography, as well as other techniques, such as tissue harmonic imaging, the cross-beam technique and the speckle-reduction technique, which employ different echo processing methods for contrast improvement and enhanced delineation of body structures adjacent to the vessels. The introduction of contrast enhanced ultrasound represents an important advancement and has brought a substantial improvement in sensitivity. This article describes and discusses these new techniques and methods of vascular ultrasound diagnostics with respect to their diagnostic value.     

Ergebnisse der primären Strahlentherapie beim Vaginalkarzinom

Background

Cancer of the vagina is the least frequent primary malignant tumor of the female genital tract except carcinoma of the fallopian tube. Radiation therapy is the preferred treatment in most cases.

Patients and Method

Between 1965 and 1991, 39 patients (median age 66 years) with primary carcinoma of the vagina were treated with radiation therapy at our clinic. The mean observation period was 37 months. Classification according to the FIGO yielded a stage I in 43%, stage II in 24%, stage III in 22% and stage IV in 11%. Histological differentiation resulted in 35 squamous cell carcinomas and 4 adenocarcinomas. In 69%, the tumor was found on the posterior or lateral wall of the vagina, in 43% it arose from the upper third of the vagina. Standard therapy consisted of combined brachy-and teletherapy. Most of the brachytherapy applications were performed with a radium source.

Results

Median survival was 37 months, calculated according to the Kaplan-Meier method. The 5-year actuarial survival rate for all stages was 41% (stage I: 62%, stage II: 44%, stage III: 25%). Sixty-eight percent of all patients achieved a complete remission, 19% a partial response. Significant prognostic factors were stage of disease and histological grading.

Conclusion

Our results demonstrate the value of radiation therapy for the treatment of primary carcinoma of the vagina. Combined treatment with both external beam radiation and brachytherapy should be preferred.     

Quantitative Analyse der linksventrikulären Wandbewegung mit MR-tagging

ZusammenfassungZielsetzung Ziel dieser Studie war es, verschiedene Parameter der linksventrikulären Wandbewegung aus MR-tagging-Aufnahmen quantitativ zu analysieren. Die Auswertemethode sollte angewendet werden, um den physiologischen Kontraktionsablauf zu charakterisieren und pathophysiologische Veränderungen zu erfassen.Material und Methoden Die Tagginguntersuchung wurde in einer basisnahen, mittventrikulären und einer apikalen Schicht des linken Ventrikels durchgeführt. Für die automatische Quantifizierung von Rotation, Kontraktion und Umfangverkürzung wurde eine geeignete Software erstellt. Die Methode wurde bei 8 gesunden Probanden, 13 Patienten mit Aortenstenose vor und ein Jahr nach Klappenersatz und 10 Patienten mit Myokardinfarkt vor und nach Revaskularisation angewendet.Ergebnisse Die von uns entwickelte Software gestattet die Quantifizierung der linksventrikulären Wandfunktion über die Bestimmung von Rotation, Kontraktion und Umfangsverkürzung. Bei den Probanden zeigte sich eine Wringbewegung mit gegenläufiger Rotation der Herzbasis zur Herzspitze. Vor Klappenersatz zeigten die Patienten mit Aortenstenose eine signifikant verstärkte apikale Rotation und Torsion. Ein Jahr postoperativ hatte sich die Torsion normalisiert. Bei den Patienten mit Myokardinfarkt zeigte sich nach Revaskularisierung eine Zunahme der Umfangverkürzung im Infarktareal.Schlussfolgerungen Die Quantifizierung der linksventrikulären Wandbewegung mit MR-tagging-Aufnahmen ermöglicht die Charakterisierung und Verlaufsbeobachtungen von Veränderungen der linksventrikulären Wandfunktion bei verschiedenen Herzerkrankungen.     

Stellenwert der Galaktographie zur Abklärung pathologischer Sekretion in der komplementären Mammadiagnostik

Background

The survey results of a previous study showed that galactography is now rarely used in Germany and newer methods are applied. The evidential value of galactography should be established and opposed to the evidential value of ultrasound (US) and magnetic resonance mammography (MRM).

Materials and methods

A search was carried out in PubMed and Cochrane involving studies written in English or German. The level of evidence was measured according to the Oxford Centre for Evidence-based Medicine.

Results

A total of 19 studies were included, 14 with results on galactography, 10 on US and 5 on MRM. Almost all studies were retrospective with an evidence assigned to level 3b or lower. The results on the diagnostic values showed a very wide range. Because of very variable numbers of cases and consideration of various pathologies, the studies are only comparable to a limited extent.

Conclusion

Galactography, US and MRM all show a weak level of evidence and no superiority of a particular method can be derived. Therefore, galactography can no longer be considered as a mandatory standard in modern multimodal imaging of the breast. Recommendations for the diagnostic work-up of pathological nipple discharge have to be included in current guidelines and must consider these facts.     

Prognostischer Wert der kardiovaskulären MRT bei Diabetikern

Die Radiologie - Trotz eines im Durchschnitt erhöhten kardiovaskulären Risikos sind Diabetiker eine heterogene Population mit höchst unterschiedlichen individuellen...     

Gesundheitsökonomie in der kardiovaskulären Bildgebung

New medical treatment methods and procedures usually cause high additional costs. Medical progress in cardiovascular imaging may fortunately reduce costs considerably. In Innsbruck it is calculated that about 1000 euros may be saved when replacing diagnostic coronary angiography (CAG) by CT coronary angiography (CTA). If in Austria 30% of CAGs are replaced by CTAs with a 64-slice CT system, about 13 million euros may be saved provided that CAG capacities will be reduced to the same extent as CTAs are done.     

Stellenwert der Galaktographie zur Abklärung pathologischer Sekretion in der komplementären Mammadiagnostik

Purpose

Galactography has been used in cases of pathological discharge for decades. Meanwhile other methods, such as high-resolution ultrasound (US) and magnetic resonance mammography (MRM) have been established for modern multimodal breast imaging. A survey among certified German breast care centers aimed to investigate to what extent galactography is currently used and whether newer techniques in multimodal imaging are preferred.

Materials and methods

An anonymous online survey was carried out nationwide and open to 342 radiology units in certified German breast care centers.

Results

A total of 177 units (52?%) participated in the survey of which 13?% generally do not provide galactography, 33?% conduct a maximum of 5 galactographies per year, 24?% conduct 6–10, 18?% 11–20, 8?% 21–50 and 5?% 51–100. Of the participants 53?% give first priority to US and prefer galactography to MRM in stepwise diagnosis and 32?% prefer MRM to galactography. Only 4?% use galactography initially.

Conclusion

Currently galactography is no longer a mandatory standard and newer methods are preferred. The evidential value of galactography in comparison to other techniques should be established on the basis of the literature. The second part of this paper will deal with this question.     

Radiologische Frühdiagnostik der skapholunären Dissoziation (SLD)

The partial tear of the scapholunate ligament (pre-dynamic stage of SLD) as well as the complete tear (dynamic stage) does not lead to carpal malalignment. However, if the completely ruptured ligament is accompanied by lesions of the extrinsic ligaments, both the scaphoid and the lunate are malaligned already at rest (static stage of SLD). Later, osteoarthritis will develop, beginning in the radioscaphoid compartment, progressing to the midcarpal joint, and ending in a carpal collapse (osteoarthrotic stage of SLD). Dynamic SLD is detectable only in stress views and in cinematography. The high utility of MRI for directly visualizing the injured ligament is emphasized: reparation tissue is focally enhanced at the rupture site by intravenously applied contrast agent; the individual segments of the scapholunate ligament can be visualized in direct MR arthrography, therefore allowing differentiation of partial and complete ligamentous tears.     

Strahlenbehandlung von follikulären Keimzentrumslymphomen

Purpose

Follicle centre lymphoma grade I, II (REAL) or centroblastic-centrocytic lymphoma (Kiel classification) present a well defined clinical entity from a clinical point of view. These lymphomas are not curable by chemotherapy in early or advanced stages. They are treated by radiation therapy in early stages, but up to now the curative potency of radiotherapy has not been confirmed by prospective clinical trials.

Patients and Method

Between January 1986 and August 1993 117 adults with follicle centre lymphoma were recruited from 24 institutions to enter the multicentric prospective, not randomised clinical trial. Patients with histologically proven nodal follicle centre lymphoma of stages I, II and limited III were included. They were treated by a standardised radiotherapy regimen, in stage I by extended field and in stages II and III by total nodal irradiation. Dose per fraction was 1.8 to 2.0 Gy, in the abdominal bath 1.5 Gy up to a total dose of 26 Gy in adjuvant situation and 36 Gy to enlarged lymphoma.

Results

All patients developed a complete remission at the end of radiotherapy. Median follow-up is 68 months. Overall survival of all patients is 86±3% at 5 and 8 years. Stage adjusted survival at 5 and 8 years was 89% for stage I, 86% for stage II and 81% for III. Patients in stages I and II <60 years had survival rates of 94% at 5 and 8 years, patients >60 years 63% (p < 0.0001). Recurrence free survival of all patients is 70% at 5 and 60±5% at 8 years. The number of recurrences is high with 29% at 5 and 41% at 8 years. All recurrences were seen within 7 years. The probability of localised nodal in-field recurrences is 11% and 22% at 5 and 8 years, respectively. Adverse prognostic factors were identified by multivariate analysis: age >60 years, treatment breaks ≥7 days and dose deviations >20% from prescribed doses Acute side effects of extended field irradiation were moderate.

Conclusions

On the basis of these results radiotherapy is a potentially curative therapeutic approach in stages I, II and limited III of follicle centre lymphoma. The optimal technique is total lymphoid irradiation with doses of 30 Gy in the adjuvant situation and 40 to 44 Gy in enlarged lymphomas. The number of local recurrences leads to the assumption that the extension of radiotherapy to the total lymphoid system might reduce their frequency.     

Intubation und Sedierung bei der endovaskulären Therapie des akuten Hirninfarkts

In the past complex intracranial treatments demanded intubation and general anesthesia of the patient. With increasing rate of endovascular local treatment of acute stroke more and more neurointerventionalists report that recanalisation techniques can be performed in sedation of the patient without the need of additional intubation. Although prospective studies are lacking retrospective studies have shown that the risk of iatrogeneous vessel injuries without global anesthesia is not increased but outcomes in case of conscious sedations are better compared with intubation and general anesthesia.     

Neue Aspekte der MRT-Bildgebung zur Diagnostik der Großgefäßvaskulitiden sowie der primären Angiitis des zentralen Nervensystems

Vasculitis is a rare disease and clinical symptoms are often unspecific. Accurate and early diagnosis is mandatory in order to prevent complications, such as loss of vision or stroke. Imaging techniques can contribute to establishing a definite diagnosis and to evaluate disease activity and the extent of the disease in various vascular regions. Conventional imaging methods, such as computed tomography (CT) and magnetic resonance (MR) angiography, as well as digital subtraction angiography allow the vessel lumen but not the vessel wall to be depicted. However, vasculitis is a disease which primarily affects the vessel wall, therefore conventional imaging modalities often fail to make a definite diagnosis. Recently black-blood high resolution MR in vivo imaging has been used to visualize cervical and intracranial vasculitis. This review article presents imaging protocols for intracranial and cervical black-blood MR imaging and clinical cases with large vessel vasculitis and vasculitis of the central nervous system. Furthermore the current literature, examples of the most common differential diagnoses of cervical and cranial arteriopathy and the potential of other imaging modalities, such as PET/CT and ultrasound will be discussed.