Cardiac tumors

Summary Tumors of the heart are very rare. Due to the nonspecific clinical presentation the diagnosis is usually made by radiological procedures. Cardiac myxomas and thrombi are the most common cardiac masses. Two-dimensional echocardiography is the method of choice for the initial evaluation of cardiac tumors, because it permits the accurate determination of the tumor's size, localization, point of attachment, mobility and haemodynamic significance. Inadequate or nondiagnostic ultrasound examination and the need for preoperative assessment are indications for further examinations, such as magnetic resonance imaging (MRI) and computed tomography. Both these methods are helpful in the assessment of paracardiac structures and of the tumor invasion into great vessels and the mediastinum. MRI allows a limited degree of assessment of whether or not the tumor is malignant by soft tissue characterization. In the case of resectable, symptomatic, cardiac tumors surgical excision should be performed. Eingegangen am 23. Dezember 1996 Angenommen am 10. Januar 1997     

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     

Dissection of retroesophageal aortic diverticulum and descending aorta in a patient with right aortic arch: Magnetic resonance demonstration

An acute aortic dissection involved the retroesophageal aortic diverticulum (RAD) and descending thoracic aorta in a patient with right aortic arch. The RAD, which was separated into false and true lumens by an intimal flap—the classic diagnositc sign of aortic dissection—was overlooked on transesophageal echocardiography and computed tomography but was clearly depicted on magnetic resonance imaging (MRI). It was found that MRI can delineate the anatomy of a congenital arch anomaly complicated by great vessels disease.     

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     

Pericardium – Radiological diagnostics

Summary Evaluation of the pericardium using the capabilities of computed tomography (CT) and magnetic resonance imaging (MRI) remains one of the last requests to the radiologists within the spectrum of cardiac diagnostics. New technical developments in CT and MRI improve diagnostic acuracy in diagnosing pericardial disease and help to define adequate therapeutic management. The purpose of this article is to review the diagnostic possibilities of the radiologist in pericardial diseases with emphasis on CT and MRI. The anatomy of the normal pericardium including pericardial recessus and sinuses is reviewed followed by a brief discussion of congenital abnormalities. Particular attention is paid to acquired pericardial diseases including the potential characterization of pericardial effusions. Pericardial thickening and pericardial constrictions are discussed and the differentiation between pericardial constriction and restrictive cardiomyopathy is highlighted because of the therapeutic implications. Finally a brief review of primary and metastatic pericardial tumours is given. Eingegangen am 30. Januar 1997 Angenommen am 5. Februar 1997     

Imaging strategies in focal hepatic disease

Introduction: Advanced therapies are improving significantly the survival of patients with malignant focal liver disease. For efficient implementation of these surgical and interventional techniques a clear concept of the diagnostic procedere is mandatory. Methods: Based on a review of the current literature, the different imaging modalities, including ultrasound, computed tomography, magnetic resonance tomography, nuclear medicine and angiography, are discussed and evaluated for their diagnostic efficacy in focal hepatic disease. Results: Considering clinical, diagnostic, and economical appropriateness, recommendations for diagnostic strategies in different clinical scenarios regarding focal hepatic disease are presented. Conclusion: If the power of specific imaging methods and relevant clinical information is known, problem-based diagnostic strategies help to avoid unnecessary, expensive and time-consuming studies in the work-up of focal liver lesions.      

Intramural hematomas of the aorta

Intramural hematomas (IMH) are regarded as a hemorrhage into the aortic wall. In general a traumatic form can de differentiated from a spontaneous non-traumatic. There is a predisposition of IMH with arterial hypertension and mesoectodermal dysplastic syndromes. The diagnosis is established with the clinical presentation in combination with the findings of different imaging modalities. Acute and subacute discomfort associated with a tendency of collaps are considered as typical presenting complaints. A semicircular or concentric thickening of the aortic wall with the absence of blood flow or a dissection membran are typical findings in transesophageal echocardiography, computed tomography and magnetic resonance tomography. From a differential diagnostic point of view a distinction from atherosclerotic wall changes, intraluminal thrombi and inflammatory aortic diseases is essential. The IMH is considered as an early presentation of aortic dissection, put into and treated according to the Stanford classification. In the course of natural history an IMH can disappear, rupture or progress into a classic aortic dissection.     

Congenital diseases of the thoracic aorta. Role of MRI and MRA

Aortic malformations may be associated with other congenital heart abnormalities or may present independently, as incidental findings in asymptomatic patients. For more than 30 years, conventional imaging techniques for detection and assessment of congenital anomalies of the aorta have been chest X-ray, echocardiography and angiography. In recent times, considerable interest in congenital aortic diseases has been shown, due to technical progresses of noninvasive imaging modalities. Among them, magnetic resonance imaging (MRI) almost certainly offers the greatest advantages, especially in young patients in which a radiation exposure must be avoided as much as possible. MRI provides an excellent visualization of vascular structures with a wide field of view, well suited for evaluation of the thoracic aorta malformations. With the implementation of magnetic resonance angiography (MRA) it is also possible to depict any relationship with supra-aortic or mediastinal vessels. Phase contrast technique allows identification of the hemodynamic significance of the aortic alteration. Some technical considerations, which include fast spin-echo, gradient-echo and, especially, MRA techniques with phase-contrast and contrast enhanced methods, are discussed and applied in the evaluation of congenital thoracic aorta diseases.     

Valvular heart disease

Summary Although valvular stenosis may be evaluated adequately by measuring transvalvular pressure gradients with Doppler echocardiography and cardiac catheterization, these methods have failed to provide reliable and accurate quantification of valvular regurgitation. In recent years the development of magnetic resonance imaging has broadened the diagnostic spectrum in cardiology, since it allows assessment of ventricular volumes without geometrical assumptions and the non-invasive quantification of blood flow within the heart and great vessels. The purpose of this overview is to evaluate “established” diagnostic tools and to show the capabilities of magnetic resonance imaging in the assessment of valvular heart disease. Eingegangen am 18. Dezember 1996 Angenommen am 19. Dezember 1996     

Rationale diagnostic approach to biliary tract imaging

Summary Since the introduction of MR cholangiography (MRC) diagnostic imaging of the biliary tract has been significantly improved. While percutaneous ultrasonography is still the primary examination, computed tomography (CT), conventional magnetic resonance imaging (MRI), as well as the direct imaging modalities of the biliary tract – iv cholangiography, endoscopic-retrograde-cholangiography (ERC), and percutaneous-transhepatic-cholangiography (PTC) are in use. This article discusses the clinical value of the different diagnostic techniques for the various biliary pathologies with special attention to recent developments in MRC techniques. An algorithm is presented offering a rational approach to biliary disorders. With further technical improvement shifts from ERC(P) to MRC(P) for biliary imaging could be envisioned, ERCP further concentrating on its role as a minimal invasive treatment option.      

Ruptured type B aortic dissection presenting with right hemothorax

We report a patient with type B aortic dissection which ruptured into the right hemithorax to call attention to this infrequent presentation and to accentuate the value of computed tomography angiography (CTA) with multiplanar reformatting in localizing the dissection and demonstrating the rupture site. CTA in combination with 2- and 3-dimensional reformatting is crucial for surgical planning because of the low specificity of transesophageal echocardiography in the ascending aorta.     

Non-invasive imaging of the great vessels of the chest

Several excellent imaging modalities are available for studying the great vessels of the chest noninvasively. Besides computed tomography (CT), magnetic resonance imaging (MRI) and echocardiography (in particular the transesophageal approach) can accurately depict abnormalities of the thoracic vasculature, and are a valuable substitute for contrast angiography in most circumstances. The aim of this paper is to provide a comprehensive review of the current contribution of CT and MRI to the diagnosis of great vessel pathology of the chest. Received 8 April 1998; Accepted 16 April 1998     

Electron-beam-computed-tomography of the heart

Summary Using electron-beam computed tomography (EBCT) with short exposure times of 100 or 50 ms and the capability of acquiring up to 2 × 17 images/s it is possible to study most of the important morphological and functional determinants of the heart. Various examples of studies in acute and chronic cardiac diseases are shown to demonstrate the use of EBCT to determine quantitatively left ventricular volumes (ml), myocardial mass (g), wall thickness changes over the cardiac cycle (mm/s), myocardial perfusion (ml/100 g/min) and the extent of coronary calcification (calcium score) and qualitatively the state of the proximal 4–6 cm of the subepicardial coronary arteries. The knowledge of these determinants seems very useful in excluding cardiac dysfunction, in the early recognition of cardiac disease and in the evaluation of the haemodynamic severity of coronary artery stenotic lesions. Further interdisciplinary studies are necessary to assess the clinical validity of these cardiac determinants, especially myocardial perfusion, using this advanced CT technology. Eingegangen am 27. Januar 1997 Angenommen am 27. Januar 1997     

Aortic dissection presenting as spinal cord ischemia with a false-negative aortogram

This article presents a case of type III aortic dissection presenting as a spinal cord syndrome with a prospectively negative initial aortogram. The patient serendipitously illustrates a multimodality approach to aortic dissection imaging. The advantages and disadvantages of conventional radiography, aortography, computed tomography, echocardiography, and magnetic resonance imaging are discussed.     

Review of CT angiography of aorta

The most common imaging modality used for diagnosis of aortic disease is CT, followed by transesophageal echocardiography, MRI, and aortography. If multiple imaging is performed, the initial imaging technique most frequently employed is computerized tomography. During the past decade, computed tomographic angiography (CTA) has become a standard non-invasive imaging modality for the depiction of vascular anatomy and pathology. The quality and speed of CTA examinations have increased dramatically as CT technology has evolved from-channel spiral CT systems to multichannel (4-, 8-, 10- and 16-slice) spiral CT system. The quality and speed of CTA is superior to other imaging modalities, and it is also cheaper and less invasive. CTA of the aorta has proven to be superior in diagnostic accuracy to conventional arteriography in several applications.     

Hemorrhagic brain abscess in infective endocarditis

We report a case of infective endocarditis (IE) that presented with acute neurological deterioration due to bleeding into a brain abscess disseminated from mitral valve vegetation. The patient recovered following surgical evacuation of hemorrhage/abscess and prolonged systemic administration of antibiotics. Although IE causes various neurological complications including intracranial hemorrhage, hemorrhagic brain abscess in patients with IE is rare. Appropriate combination of diagnostic modalities including computed tomography, magnetic resonance imaging, cardiac ultrasonography, and cerebral angiography, together with careful evaluation of the clinical history, leads to accurate diagnosis and treatment of patients with IE presenting with neurological complications.     

Tumors of the cardiac valves: imaging findings in magnetic resonance imaging, electron beam computed tomography, and echocardiography

We describe the findings from various cross-sectional imaging modalities in patients with cardiac valve adherent masses. The techniques are discussed, and imaging findings are compared with the results of cardiac surgery. All three patients had neurological symptoms and/or cardiac murmurs. Transthoracic and/or transesophageal echocardiography revealed the cardiac mass in all three. For differentiation of thrombus and cardiac neoplasm magnetic resonance imaging (MRI) was also performed in all three patients and electron-beam computed tomography (EBCT) in two. Fast segmented cine gradient-echo MRI techniques provided mass depiction in all patients, while T1-weighted spin-echo imaging failed in mass detection in one patient. None of the patients showed evidence of valve regurgitation or stenosis in flow sensitive cine MRI. EBCT excluded mass calcifications in both patients and reliably demonstrated the valve attached lesions. Although echocardiography is the modality of choice in evaluating cardiac masses and especially valve attached masses, MRI and EBCT provide additional information about tissue characteristics and allows an excellent overview of the cardiac and paracardiac morphology. Fast segmented cine gradient-echo MRI is especially able to depict even small tumors attached to rapidly moving cardiac valves, and valve competence can be easily assessed within the same examination. Received: 17 December 1998; Revision received: 1 June 1999; Accepted: 10 August 1999     

Bildgebende Verfahren in der Diagnostik des Herzens

PURPOSE: Cardiac imaging includes determination of the size and structure of the cardiac chambers, valves, great vessels and the coronary arteries, chamber and valvular function, myocardial perfusion, viability and metabolism. MATERIAL AND METHODS: Chest roentgenography, angiography, echocardiography and nuclear imaging are commonly used but computed tomography and magnetic resonance imaging also offer a promising potential. RESULTS: Coronary angiography is the gold standard in assessing coronary anatomy. Fast CT technologies such as electron-beam and multi-low-CT are promising non-invasive imaging modalities in the assessment of coronary artery disease. With intravascular ultrasound early stages of coronary atherosclerosis can be detected. For the assessment of myocardial perfusion and viability as well as cardiac function, scintigraphic methods are widely accepted. However, MRI methods have also reached a high degree of accuracy. Evaluation of chamber and valvular function is, due to its wide availability, the field of echocardiography. CONCLUSIONS: In clinical routine chest roentgenography, angiography, echocardiography and nuclear imaging are well established. The value of computed tomography and magnetic resonance imaging in the evaluation of coronary artery disease, myocardial perfusion, viability and metabolism is yet to be defined.     

Imaging the vertebral artery

Although conventional intraarterial digital subtraction angiography remains the gold standard method for imaging the vertebral artery, noninvasive modalities such as ultrasound, multislice computed tomographic angiography and magnetic resonance angiography are constantly improving and are playing an increasingly important role in diagnosing vertebral artery pathology in clinical practice. This paper reviews the current state of vertebral artery imaging from an evidence-based perspective. Normal anatomy, normal variants and a number of pathological entities such as vertebral atherosclerosis, arterial dissection, arteriovenous fistula, subclavian steal syndrome and vertebrobasilar dolichoectasia are discussed.     

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