Gynecological disease causing acute abdominal pain in childhood

Summary In cases of acute abdominal pain in girls a gynecological cause must always be considered. Neoplasms and cystic adnexal lesions complicated by hemorrhage, torsion, and infarction can be diagnosed in childhood. Ovarian tumors without endocrine activity are frequently very large at the time of discovery. Intravaginal foreign bodies, inflammation, and congenital obstructive malformations are seldom found in patients with acute abdominal pain. Ultrasound has become the diagnostic method of choice. When used by an experienced examiner, its results are nearly as good as MRI. In evaluation with clinical data and serological results, an exact diagnosis can be made by ultrasound, even if the sonomorphological pattern seems confusing. Solid adnexal mass and complex malformations require MRI as a complementary diagnostic step. X-ray studies and computed tomography are less important diagnostic tools in girls with acute abdominal pain caused by gynecological disease. Eingegangen am 20. Dezember 1996 Angenommen am 5. Januar 1997     

Appendicitis in childhood

Summary From 1989 to 1995 high-resolution ultrasonography (US) was performed in 3,546 children (age: 1–17 years) with clinically suspected appendicitis. A total of 518 patients underwent laparotomy; 420 had histologically proven acute or perforated appendicitis (prevalence 11.8 %). In these children, the sensitivity, specificity and overall accuracy of US examination were 90 %, 97 % and 96 % respectively. The use of US in clinically doubtful acute abdomen may allow earlier diagnosis of acute appendicitis; in 1995 the rate of unnecessary appendectomy was reduced to 13 %. Eingegangen am 15. Dezember 1996 Angenommen am 5. Januar 1997     

Imaging diagnosis of the larynx. Normal anatomy and pathological changes

Summary The primary goal of diagnostic imaging of the larynx is analysis of submucosal structures that are not visible by clinical or endoscopic means. Therefore, image analysis of the larynx should only be performed under knowledge of the results of clinical diagnosis. The anatomic relationships of the laryngeal skeleton, the intrinsic structures, and the surrounding soft tissue are presented synoptically.      

Imaging techniques in the diagnosis of coronary heart disease

Summary Coronary heart disease is the leading cause of death and disability worldwide. Coronary angiography makes it possible to visualize coronary artery stenosis and can be used for angioplasty and stent implantation; however, it does not allow the assessment of changes in myocardial microcirculation. The severity of an angiographically evaluated coronary stenosis does not always correspond to the extent of myocardial ischemia. Noninvasive techniques are needed to re-examine our reliance on coronary angiography and to explore the clinical value of the physiological assessment of coronary artery stenoses. Such noninvasive techniques might become important tools in the future following an overal evaluation of coronary morphology, myocardial function and perfusion ascertained by all available methods. Eingegangen am 8. Januar 1997 Angenommen am 9. Januar 1997     

Punch biopsy or fine needle aspiration biopsy in percutaneous puncture

Purpose: The diagnostic accuracy and rate of complications of CT-guided core biopsies (CB) from suspected tumors of the chest were compared to the accuracy a complications of fine-needle aspiration biopsies (FNAB). Methods: The accuracy in the diagnosis of a benign or malignant lesion of 79 FNAB (19.5 G self-aspirating cutting needle) and of 83 CB (18 G automated core biopsy) and the rates of pneumothorax, pleural drainage and hemoptysis were retrospectively evaluated. Results: With FNAB, the sensitivity for malignant lesions was 62.1 % and the accuracy 68.4 %. With CB the sensitivity amounted to 85.9 % and accuracy to 86.7 %. The rate of pneumothorax was 25.3 % following FNAB, with a drainage rate of 5.1 % compared to 19.3 % and 6.0 %, respectively, following CB. The rate of pneumothorax and drainage increased with increasing path length through aerated lung. In advanced emphysema, the pneumothorax rate did not increase; however, in pneumothoraces, pleural drainage was mandatory in 20 % of FNAB and in 100 % of CB. Hemoptysis without any therapeutic consequences occurred in 3.8 % following FNAB and in 6.0 % following CB. Conclusions: With CB diagnostic accuracy can be clearly increased without an obvious increase in the complication rate. However, in patients with obvious emphysema, the pleural drainage rate of pneumothorax may be higher following CB.      

Hand and wrist imaging using a low-field dedicated MRI system

Summary Purpose of this study was to evaluate the diagnostic value of a low field dedicated MRI system in hand and wrist imaging. All 308 exams of the hand and wrist, that were performed on a low-field dedicated MRI system (Artoscan, Esaote Biomedica, Italy) in our institution in 1996, and high-field MRI exams performed in addition as part of the diagnostic work-up, were evaluated and correlated to final operative (n = 64) and histologic (n = 12) reports. 90 % of all low-field MRI scans stated a diagnosis according to clinical suspicion. In 62 % the clinical question was answered, and in 26 % additional pathologies were identified. An MR-diagnosis completely different from the clinical suspicion was stated in 2 %. High field exams contributed additional information in 6 of 36 patients. In 3 patients a tumor was not shown completely in the limited field-of-view of the dedicated low-field MRI-system. Frequency-selective fat-suppression pulse sequences and a better spatial resolution were the reasons for the additional information obtained in the other three patients. Low-field dedicated MR-imaging is a valuable method in the extensive work-up of the hand and wrist. Osseous, ligamentous and tendinous pathologies are well depicted. Large or infiltrative tumors should be referred to a high-field system.      

Commercial teleradiology systems in Germany

Summary Teleradiologysystems can differ considerably in their features. The most important differences lie in the mode of image data acquisition, data transfer, data safety aspects and the possibilities of interaction between seperate teleradiology units. A selection of commercially available teleradiologysystems is presented and compared. Eingegangen am 3. Februar 1997 Angenommen am 19.Februar 1997     

MR-guided biopsies

Summary Biopsies were the first “intervention” under MR guidance. After initial difficulties concerning ferromagnetic biopsy instruments and the design of MR scanners, the latest technological improvements rendered MR guidance for biopsies more feasible. In this article we illustrate present-day clinical experience in the field of abdominal, breast and bone biopsy. Important aspects regarding the different designs of “interventional” MR scanners and the visualization of instruments for biopsy are discussed.      

Integrated screening concept in women with genetic predisposition for breast cancer

Summary Breast cancer is in 5 % of cases due to a genetic disposition. BRCA1 and BRCA2 are by far the most common breast cancer susceptibility genes. For a woman with a genetic predisposition, the individual risk of developing breast cancer sometime in her life is between 70 and 90 %. Compared to the spontaneous forms of breast cancer, woman with a genetic predisposition often develop breast cancer at a much younger age. This is why conventional screening programs on the basis of mammography alone cannot be applied without modification to this high-risk group. In this article, an integrated screening concept for women with genetic predisposition for breast cancer using breast self-examination, clinical examination, ultrasound, mammography and magnetic resonance imaging is introduced.      

Diagnostic strategies in bone tumors and tumor-like lesions

Summary Real bone tumors are rarely encountered in the daily routine of radiological practice. Therefore, for a general radiologist there is no need for a specialist knowledge on this field. However, he should be able to distinguish benign from malignant lesions in order to avoid unnecessary biopsies. A systematic approach towards osteolytic lesions, e. g. according to the classification of Lodwick, is mandatory. CT and MRI are indicated to clear up the anatomy in areas of superposition artefacts in conventional radiology and to determine the inner structure of a lesion, e. g. fatty tissue, liquid/solid. This paper highlights the advantages and disadvantages and the cost-effective use of the imaging modalities including scintigraphy in the diagnosis of bone tumors and tumor-like lesions. Guidelines for the management of bony lesions will be given in detail. The option and necessity for a specialist second opinion is emphasized.      

Telemedicine – possibilities and perspectives

Summary The discussion about the implementation of telemedicine and teleresourcing and its consequences has been under way for some time now. The rate at which telemedical applications are being developed, leaves little time for consideration of the economic, scientific and social aspects. There is a need for integration of all the existing fragments into one coherent telemedical concept. Different aspects of telemedical concepts are discussed. Eingegangen am 20. Januar 1997 Angenommen am 19. Februar 1997     

Videofluoroscopic evaluation of complications after laryngeal resection

Summary In past decades, the surgical techniques for treating laryngeal carcinoma have been vastly improved. For circumscribed tumors, voice-conserving resections are possible and for extensive neoplasms, radical laryngectomy, sometimes combined with chemoradiation, has been developed. Postoperative complications regarding swallowing function are not uncommon. Radiologic examinations, especially pharyngography and videofluoroscopy, are most often used to evaluate patients with complications after laryngeal surgery. An optimized videofluoroscopic technique for evaluation of complications is described. The radiologic appearance of early and late complications, such as fistulas, hematomas, aspiration, strictures, dysfunction of the pharyngoesophageal sphincter, tumor recurrence, and metachronous tumors is demonstrated.      

Intestinal emergencies in newborns

Summary Imaging plays a major role in most neonatal gastrointestinal emergencies. The role may vary from helping to establish a diagnosis, to the evaluation of associated abnormalities, to surgical planning, or to therapy for some conditions like meconium ileus or meconium plug syndrome. Plain radiographs and ultrasound serve a primary imaging modalities with bowel contrast examinations, CT scan, and MR imaging playing roles in more complex cases. Eingegangen am 30. Dezember 1996 Angenommen am 15. M?rz 1997     

Physiology of the larynx

Summary The larynx consists of the cartilaginous-osseous framework, elastic membranes and ligaments, joints, muscles, nerves, vessels, and interior cavity. The laryngeal functions are the protection of the airway during swallowing, respiration (i. e. maintainance of the airway) and phonation. During the pharyngeal phase of swallowing the swallow reflex induces a laryngeal closure in three levels and a superior-anterior movement of the larynx and hyoid bone. The laryngeal airway is maintained by the circumference of the cricoid cartilage. Phonation is the phylogenetically recent function of the larynx and was made possible by the laryngeal descent. The sound production is explained according to the myoelastic-aerodynamic theory. The diagnostics of laryngeal diseases is performed in close cooperation between otorhinolaryngology and radiology. For diagnostic purposes, the physiology of the larynx requires to take into account not only morphological, but also functional aspects.      

The value of ultrasonography of the Achilles tendon in traumatology

Summary Method: In an experimental study on ten isolated human cadaver tendons, the ultrasound anatomy and the reproducibility of aretefacts was determined using 10- and 13-MHz probes. With these in vitro data, the form and diameter of a non-injured tendon were documented in a series of 30 patients between 3 and 60 years old. In a second series of 32 patients with acute, traumatic ruptures of the Achilles tendon and 40 patients with chronic disorders, we distinguished the pathological anatomy. Results: Injuries to a tendon with chronic disorders, reruptures and complications in the postoperative period after tendon repair can be made more difficult by calcification, scars, oedema, haematoma and suture materials. It is necessary to check the changing ultrasound patterns owing to an haematoma or oedema with tendon corpulence, the missing linear signals in a fresh rupture and the different signals after operative or non-operative treatment. Conclusion: Using high-frequency probes with 10 or more MHz, it is possible to examine even the insertion area of the tendon or the pathology of a subachilleal bursa by tilting the probe. The dynamic examination and the comparison with the contralateral side in two planes should be included in a standardized examination procedure and are of great importance in some cases of fresh tendon ruptures. Knowledge of the physical principles and the possibility of misleading artefacts is crucial.      

Sonoanatomy of the foot

Summary To show the possibilities of imaging diagnostic procedures using high and extremely high resolution ultrasonic probes we investigated the anatomic structures of the foot. We examinated 10 cadaver foots of the anatomic institute and in a clinical trial 20 healthy patients with 10 to 20-MHz-probes and could identify correctly single tendons and ligaments even in the toe region. Especially the possibility of dynamic examination had to be mentioned beside the other advantages of ultrasound diagnostic (saving of expenses, lack of radiation, side-to-side comparison).      

Meningeal hemangiopericytoma in childhood

Meningeal hemangiopericytoma (MHP) is extremely rare in childhood. Mean age at diagnosis is between 38 and 43 years. We present an 8-year-old boy with MHP of the middle cranial fossa. Imaging findings were indistinguishable from an aggressive bone tumor such as Ewing's sarcoma. Imaging findings are presented and discussed. Our case indicates that MHP should be considered in the differential diagnosis of skull-base tumors despite the fact that MHP is extremely rare in childhood. Received: 8 July 1999; Revised: 28 September 1999; Accepted: 29 September 1999     

Quantitative morphology of the vertebral body cortex

Summary The vertebral bodies consist of two main structures, trabecular and cortical bone. The histological changes within the spine, especially in cortical bone, leading to osteoporotic fractures remain, however, poorly understood. Therefore, the complete front column of the spine was removed in 26 autopsy cases without skeletal diseases and in 11 cases with proven osteoporosis. A sagittal segment prepared through the center of all vertebral bodies was undecalcified embedded in plastic, ground to a 1-mm-thick block and stained using a modification of the von Kossa method. The analysis included measurement of the mean cortical thickness of both ventral and dorsal shell (from C3 to L5). The qualitative investigation of the structure of the cortical ring completed the analysis. The skeletally intact specimens had high cortical thickness values in the cervical spine (285 ± 22 μm), a decrease in the thoracic spine (244 ± 14 μm) and an increase in the lumbar spine (290 ± 15 μm). The mean thickness of the ventral shell is in general higher than the thickness of the dorsal shell. The cortical thickness of the spine showed no gender-specific differences (P = n.s.). There was a slight decrease in cortical thickness with age; however, this decrease and the correlation of cortical thickness to age was only significant below vertebral body T8 (r = 0.225 to 0.574; P_r < 0.05 to P_r < 0.005). Most interestingly, osteoporosis is characterized by a significant decrease in cortical thickness throughout the whole spine. This decrease in cortical thickness was more marked in the dorsal shell (P < 0.05) than in the ventral shell (ventral from C3 to T6 (P < 0.05) below T6 (P = n.s.). We therefore conclude that in osteoporosis, biomechanical competence is affected by both trabecular bone loss and decrease of cortical thickness. This suggests that, in addition to trabecular bone measurements, the cortical thickness is of special interest for diagnostic radiological examinations (CT) to yield clues about the risk of vertebral fractures.      

CT angiography in carotid stenosis

Purpose: Prospective evaluation of the accuracy of CT angiography (CTA) with different postprocessing for extracranial carotid artery in comparison with DSA. Method: one hundred patients were studied with standarized CTA. For postprocessing, MPR, MIP, and 3D reconstruction based on segmentation with upper and lower threshold were used. Intravascular density profiles were considered. All CTA studies were correlated with intra-arterial angiography. The degree and classification of stenoses was determined using the guidelines established by the NASCET collaborators. Results: Measurement of stenosis was possible by MPR in 82.5 %, by MIP in 85 %, and 3D in 100 %. Correct classification was found in 65.5 % for MPR, 66 % for MIP and 88.5 % for 3D. The sensitivity for severe stenoses was 74 % for MPR, 82 % for MIP, and 93 % for 3D. The specificity of these methods was 98 %, 96 %, and 97 %, respectively. All carotid occlusions were correctly identified, no carotid artery was wrongly classified as occluded. Conclusions: CT angiography allows reliable examinations in carotid artery stenoses and occlusions. 3D reconstruction based on threshold segmentation is superior to MPR and MIP. In some circumstances, e.g., carotid occlusion, further investigation by invasive procedures is not necessary.      

Computed tomography in acute cerebral ischemia

Summary Computed tomography (CT) is the first step in the radiological diagnostics of brain emergencies. We intend to study which pathophysiological changes are detected by CT and how CT contributes to prognosis and patient management in acute cerebral ischemia. We review recent publications about the role of CT in acute cerebral ischemia. Ischemic brain edema is associated with a decreased X-ray attenuation. Computed tomography is thus highly sensitive in detecting irreversibly damaged ischemic brain tissue. Patients showing large volumes of ischemic edema, exceeding one third of the middle cerebral artery territory, do not benefit from thrombolysis and have an increased risk of brain hemorrhage. The brain territory at risk from ischemia can be detected by CT angiography. To combine CT with CT angiography is a pragmatic approach which enables carefully directed treatment in acute cerebral ischemia.