Images in cardiology. Progressive Stanford B aortic dissection treated by acute stenting.
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Aortic Dissection↗
Biomedical subjects
G Wittenberg
Publications and source records attributed to G Wittenberg.
[Workflow improvement and efficiency gain with near total digitalization of a radiology department].
PURPOSE: To determine the temporal changes of the workflow caused by digitalization of the radiology department after installation of digital luminescence-radiography (DLR), a radiology information system (RIS) and picture archiving and communication system (PACS) at the Missionsärztliche Klinik in April 2000. MATERIALS AND METHODS: In a comparative study, a workflow analysis by manual registration of different work steps was performed before (1999) and after (2001) digitalization of a radiology department. RESULTS: The digitalization shortened the examination time for patients from a mean of 8 min to 5 min. The time the patient is absent from the emergency room did not change. Reporting radiographic examinations including comparison with previous studies begins earlier from a mean of 2 h 37 min to 17 min. Using PACS, 85.9 % of all cases could be interpreted on the day of the examination (without PACS 41.2 %) and 87.2 % of the reports were completed the day after the examination (without PACS 64.5 %). No time differences were found between reading conventional studies on the monitor or as soft-copy. CONCLUSION: Compared to conventional film-screen systems, complete digitalization of a radiology department is time saving at nearly all steps of the workflow, with expected positive effects on the workflow quality of the entire hospital.
Efficiency, Organizational↗
Treatment of disseminated ocular melanoma with sequential fotemustine, interferon alpha, and interleukin 2.
Malignant melanoma of the uvea is remarkable for purely haematogenous dissemination and its tendency to metastasise to the liver. Although the liver is involved in up to 95% of patients, 50% of these also develop extrahepatic metastases, most often in the lungs, bone, skin, and brain. The only effective treatments reported to date relied on hepatic arterial chemoembolisation or -perfusion. The objective of this study was to establish a therapy protocol addressing patients with both sole liver involvement and systemic disease. Forty-eight patients with metastatic ocular melanoma received fotemustine 100 mg m(-2) either as 60-min infusion into the hepatic artery or as 15-min infusion via a peripheral vein, depending on the metastatic sites involved, i.e., restriction to the liver or hepatic together with extrahepatic disease. For the first treatment cycle this infusion was repeated after one week. For all cycles, subsequent to a three week resting period, patients received an immunotherapy consisting of subcutaneous interleukin 2 and interferon alpha(2). Although objective responses were more frequent within the cohort receiving intraarterial fotemustine (21.7 vs 8%), this difference did not translate into a significant benefit in overall survival, i.e., 369 and 349 days, respectively. Of note, this overall survival is much longer than that repeatedly reported for stage IV uveal melanoma not treated with fotemustine, suggesting a therapeutic activity of this cytostatic drug even after systemic administration.
Antineoplastic Combined Chemotherapy Protocols↗
Metallic stents and plastic endoprostheses in percutaneous treatment of biliary obstruction.
BACKGROUND: In the light of the clinical controversy whether metallic stents or plastic endoprostheses should be used in the percutaneous treatment of biliary obstruction we retrospectively evaluated our experience with both drainage-systems. METHODS: 71 patients (mean age 68 +/- 12 years) underwent a total of 81 interventions and received either plastic endoprostheses (11.5 or 12 French diameter; N = 57/81) or metallic stents (N = 24/81). RESULTS: Drainage insertion was technically successful in all of the 71 patients. There was no procedure-related mortality, but a 30-day mortality of 15 % (N = 11). Overall, 27 complications occurred in 81 interventions with a statistically significant higher complication-rate in plastic endoprostheses (39 %; N = 21/54) compared to metallic stents (22 %; N = 6/27). The average patency of the drainage-systems was 166 +/- 341 days (range 1-2,705 days) and did not differ significantly between the drainage-subtypes. Incidence of complications and a further increase in serum bilirubin following intervention was associated with a higher drainage occlusion-rate and reduced survival, irrespective of the drainage-system used. CONCLUSIONS: Percutaneous transhepatic treatment of biliary obstructions with internal drainages is a reliable therapy. The overall complication-rate of metallic stents was lower compared to plastic endoprostheses; however, no significant differences were found with respect to drainage patency or success-rate.
Adult↗
Optimization of automatic bolus tracking for timing of the arterial phase of helical liver CT.
The aim of this study was to optimize bolus tracking for timing of the arterial phase of biphasic helical liver CT and to compare optimized bolus tracking to a standard delay. One hundred fifty patients were examined with six protocols: 5- or 10-s delay after triggering at a threshold of 50 or 75 or 100 HU enhancement in the aorta at the origin of the celiac arteries after injection of 120 ml contrast material at 3 ml/s. Optimal arterial enhancement was defined as 20-30% of hepatic enhancement in portal venous phase. Another 50 patients were examined with the optimized protocol and compared to 50 gender- and age-matched patients who underwent a 25-s standard delay. A 10-s delay after the 75-HU threshold resulted in the most patients with an optimal arterial phase (p < 0.01). Thirty-one of 75 patients examined with this protocol showed optimal early liver enhancement. Bolus tracking compared with standard delay revealed only a trend for a difference (p = 0.07). The outcome of automatic bolus tracking differs depending on the protocol used; however, optimal arterial phase imaging was seen in only 41% of patients, indicating only a trend for superior timing compared with a standard delay.
Adolescent↗
[Comparison of 3D power doppler ultrasound, color doppler ultrasound and digital subtraction angiography in carotid stenosis].
PURPOSE: To compare easy-to-perform three-dimensional power Doppler ultrasound (3D PDUS) to color Doppler ultrasound (CDUS) and digital subtraction angiography (DSA) in the assessment of internal carotid artery (ICA) stenoses in patients with severe atherosclerosis. METHODS: 26 ICA's (7 without stenosis, 4 low-, 4 middle-, and 11 high-grade stenoses) in 13 patients were examined with DSA, CDUS, and 3D PDUS. CDUS and 3D PDUS were performed with a 7.5 MHz standard transducer and a Sonoline Elegra ultrasound machine. The three methods were performed and interpreted by different persons who were not aware of the diagnoses. RESULTS: Regarding the degree of stenosis correlations between DSA and 3D PDUS were r = 0.98 (p < 0.001), between DSA and CDUS r = 0.97 (p < 0.001), and between CDUS and 3D PDUS r = 0.95 (p < 0.001). Sensitivity and specificity regarding the detection of a high-degree stenosis was 90% and 100% for 3D PDUS, and 100% and 93.3% for CDUS. CONCLUSION: Even in cases with severe atherosclerosis, both sonographic methods reveal similar results comparable to DSA. 3D PDUS does not result in a diagnostic improvement on CDUS, however, it does give the new opportunity for complete data storage, reconstruction, and survey presentations.
Aged↗
[Comparison of iodinated and barium-containing contrast media of different viscosity in the detection of pharyngeal perforation].
PURPOSE: In contrast to esophageal perforations, the more radiopaque barium-suspensions are not as important as iodinated aqueous contrast agents for the detection of pharyngeal perforations. This study was performed to find out whether the highly different viscosities (of iodinated and barium-containing contrast agents with comparable radiopacities) are a reason for this. METHODS: Viscosity, subjective difference in contrast, and CT-density of an iodinated aqueous (Telebrix) and a 50 wt/vol% barium-containing contrast agent (Micropaque) were determined. Moreover, to exclude postoperative perforation, 104 patients were prospectively examined by pharyngography using both contrast media. Pharyngographies of patients with perforation were later compared by two independent readers. All patients with perforation were followed up clinically to exclude complications due to barium administration. RESULTS: In-vitro comparison showed comparable radiopacity but the 50 wt/vol% barium-suspension was much more viscous than the iodinated contrast agent. During pharyngography, totally, 14 perforations were clearly delineated with the iodinated aqueous contrast agent. However, two of them were not detected with the barium-suspension. All the other perforations presented equally. CONCLUSIONS: Given a sufficient radiopacity, a low viscosity appears to be essential for a contrast agent to detect especially pharyngeal perforations. Thus, we recommend the sole use of an iodinated contrast agent (at suspicion of aspiration as isoosmolar variant) for this purpose.
Adult↗
Sclerosing cholangitis and liver cirrhosis after extrabiliary infections: report on three cases.
OBJECTIVE: To describe three unusual cases of sclerosing cholangitis after severe extrahepatic/extrabiliary bacterial infections. DESIGN: Case report, clinical. SETTING: Tertiary care intensive care unit (ICU). PATIENTS: Three patients admitted to the ICU with infections from Gram-positive bacteria followed by sclerosing cholangitis and secondary biliary cirrhosis. MAIN RESULTS: Three unusual cases of persisting cholestasis that occurred after bacterial infections originating from extrahepatic/extrabiliary foci are described. Endoscopic retrograde cholangiopancreatography and magnetic resonance cholangiopancreatography revealed multiple strictures of the intrahepatic bile ducts as a sign of sclerosing cholangitis. All patients progressed to biliary cirrhosis within months after the onset of cholestasis. CONCLUSION: Infection-associated cholestasis is usually a functional disorder and subsides after effective treatment of the underlying inflammatory focus. In rare cases, however, extrahepatic/extrabiliary infections may lead to sclerosing cholangitis and secondary biliary cirrhosis via unknown mechanisms.
Adult↗
MR angiography of the hand arteries.
The aim of this study was to optimize different magnetic resonance angiography (MRA) techniques and to evaluate MRA of the hand arteries compared to intraarterial digital subtraction angiography (IA-DSA). The MRA examinations were performed on a 1.5-T system equipped with a flexible surface coil. The protocol contained time-of-flight (TOF), rephased/dephased (Re/De), and contrast enhanced (CE) techniques. Maximum intensity projection (MIP) was used for postprocessing. The IA-DSA procedure was performed as pharmaco-angiography (after intraarterial injection of a vasodilatator) via a transbrachial approach. Nine patients suffering from peripheral vascular disease were examined with IA-DSA, TOF-MRA, and Re/De-MRA; six patients were examined with CE-MRA and IA-DSA. Best overall image quality was attained with IA-DSA, followed by TOF-MRA, Re/De-MRA, and CE-MRA. Selective arterial visualization of digital arteries was possible with IA-DSA and TOF-MRA. Rephased/dephased MRA showed venous overlay. Contrast-enhanced MRA was limited by inconstant quality of bolus timing. Appropriate arterial bolus timing was achieved in four of six patients; one examination showed venous overlay, one examination incomplete arterial enhancement. Time-of-flight MRA detected 96% of the digital artery segments that were identified with IA-DSA and revealed 34 segments that were failed on IA-DSA. Rephased/dephased MRA and CE-MRA were inferior to IA-DSA and TOF-MRA regarding detection of digital arteries. Magnetic resonance angiography with optimized protocols is a noninvasive procedure to visualize hand arteries in patients with ischemic disease. With TOF-MRA it is possible to detect angiographically occluded arterial segments of digital arteries.
Adolescent↗
Compression repair of ruptured pseudoaneurysms guided by color Doppler ultrasonography: report of two cases.
Noninvasive treatment of ruptured postcatheterization pseudoaneurysms is rare. We report the use of ultrasonographically guided compression repair for the treatment of ruptured pseudoaneurysms in 2 cases. To ensure the immediate stop of bleeding, more compression was applied than for nonruptured pseudoaneurysms, regardless of flow in the femoral artery or vein, thus maximizing the effectiveness of this therapy. With this method, complete thrombosis of the pseudoaneurysm could be achieved in less than 30 minutes. In both cases, ultrasonographically guided compression repair was faster than the time needed to prepare an operating room for surgical treatment. In follow-up examinations, no recurrences or further complications were detected. Ultrasonographically guided compression repair can be used for noninvasive treatment of ruptured pseudoaneurysms in some cases, provided that more compression than indicated for nonruptured pseudoaneurysms is applied. Further clinical experience with more patients will be necessary to determine the exact benefits and possible limitations.
Aged↗
Asymptomatic aneurysm of the proximal right subclavian artery: a rare ultrasound diagnosis.
True aneurysms of otherwise normal subclavian arteries are uncommon peripheral vascular anomalies. Most patients with subclavian artery aneurysms are symptomatic by presenting neurologic signs. We report a young woman who had an asymptomatic true aneurysm of the right subclavian artery assumed to be of congenital origin. This case is unique in that the aneurysm was in the extremely rare anatomic location of the right supraclavicular fossa between the origins of the right subclavian artery and the vertebral artery. Aneurysms of the right subclavian artery may represent a potential pitfall in conventional gray-scale ultrasound of the neck particularly the supraclavicular fossa. Differential diagnosis includes cervical cyst, pharyngo-esophageal diverticulum, vascular anomalies, struma, enlarged lymph node, as well benign or malignant neoplasms. Color duplex ultrasound should be performed as the method of choice for further analysis of suspected aneurysms. In this report the role of B-mode ultrasound and color duplex ultrasound is discussed in relation to digital subtraction- and MR angiography in confirmation of the diagnosis.
Adult↗
Capillary leak syndrome in a patient treated with interleukin 2 fusion toxin for cutaneous T-cell lymphoma.
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Aged↗
Detection of pharyngeal perforation: comparison of aqueous and barium-containing contrast agents.
OBJECTIVE: We sought to assess the value of aqueous and barium-containing contrast agents in the detection of pharyngeal perforation. SUBJECTS AND METHODS: Visual and objective in vitro comparisons of an iodinated aqueous contrast agent, a 50% weight/volume barium suspension, and a 100% weight/volume barium suspension were performed. Moreover, to exclude pharyngeal perforation after surgery, we prospectively examined 109 patients by pharyngography, using the aqueous contrast agent and the 100% weight/volume barium suspension. All patients with a pharyngeal perforation were followed up clinically to exclude complications due to barium application. RESULTS: As opposed to the 100% weight/volume barium suspension, in vitro comparison between the aqueous contrast agent and the 50% weight/volume barium suspension yielded no substantial differences. Seventeen perforations could be detected with the aqueous contrast agent. Although 10 of 17 perforations could be slightly better visualized with the 100% weight/volume barium suspension, two perforations were missed with this agent. Five perforations were equally well detected with both. CONCLUSION: Because of a higher radiopacity, 100% weight/volume barium suspensions may more sharply delineate perforations. However, in contrast to aqueous contrast media, narrow pharyngeal perforations can be missed. Thus, the use of a 100% weight/volume barium suspension does not improve the detection of pharyngeal perforation.
Adult↗
Erdheim-Chester disease: a case report and literature overview.
Erdheim-Chester (EC) disease belongs to the group of lipoid granulomatosis. Symmetric sclerosis of the meta- and diaphysis of long tubular bones are pathognomonic radiologic changes. Additionally, other skeletal segments can be affected. Extraskeletal manifestations can occur in almost all organs; lungs, pericardium, retroperitoneum, skin, and orbita play particularly important roles. The last case of 38 cases of Erdheim-Chester disease with an extraordinary mediastinal and perirenal involvement is described. For the second time following the initial description by Chester, an axial skeletal pattern of eburnated vertebra is shown.
Aged↗
Spiral CT angiography of renal arteries: comparison with angiography.
A prospective study was carried out to determine the accuracy of spiral CT angiography (CTA) in the detection of renal artery stenosis (RAS). Eighty-two patients with arterial hypertension underwent CTA and digital subtraction angiography (DSA) to exclude RAS. For CTA a contrast medium bolus of 100-150 ml (flow rate 3 ml/s) was injected. A 24 or 40 s CTA was started at the origin of the superior mesenteric artery after a delay time determined by test bolus injection (collimation = 2 mm, pitch = 1/1.5). For stenosis detection transverse images supported by maximum intensity projections (MIP) or multiplanar reconstruction projections were used. Of 197 renal arteries examined (including 33 accessory arteries), 34 RAS were visualized using DSA. With CTA, one hemodynamic RAS was missed and one additional hemodynamic RAS was found. Sensitivity/specificity was calculated to be 94 %/98 %. For hemodynamically relevant RAS (> 50 %) the sensitivity/specificity was 96 %/99 %. CTA additionally depicted five adrenal masses. The high accuracy rate of RAS detection thus allows the use of CTA as a screening method in patients with arterial hypertension to exclude a renovascular cause.
Adult↗
Current value of double-contrast pharyngography and of computed tomography for the detection and for staging of hypopharyngeal, oropharyngeal and supraglottic tumors.
In light of recent endoscopic techniques the current value of double-contrast pharyngography (DCP) and of CT for detection and staging of hypo-, oropharyngeal, and supraglottic tumors is evaluated. The DCP of 151 patients and CT obtained from 99 of these patients were retrospectively analyzed in a double-blinded manner. We used a standard protocol which comprised all relevant anatomical subregions. Results were compared with direct microlaryngoscopy (DL), indirect laryngoscopy (IL), and post-operative histopathological findings. Sensitivity and specificity of DCP was 75.0 % and 86.7 %, respectively. The DCP and IL techniques together yielded a higher sensitivity (96.7 %) than each method separately. Sensitivity and specificity of CT was 87.5 and 100 %, respectively. In 74.7 % CT provided correct staging. Subregional analysis revealed that the results of DCP and CT depend highly on the localization of the tumor. Our results indicate that DCP represents an important screening method for diagnosing hypo-, oropharyngeal, and supraglottic tumors to complete IL and DL. We show that CT is a reliable method for preoperative staging, although small superficial tumors may occasionally be missed by this method.
Administration, Oral↗
Cushing's syndrome due to an ectopic ACTH-secreting pituitary tumour mimicking occult paraneoplastic ectopic ACTH production.
A 32-year-old man presenting with typical features of Cushing's syndrome showed baseline cortisol and ACTH values indicating ACTH-dependent disease. Dynamic function tests (dexamethasone, corticotropin releasing hormone (CRH), desmopressin), were suggestive of paraneoplastic ectopic ACTH production. However, inferior petrosal sinus (IPS) ACTH sampling demonstrated a maximum baseline central (363 pmol/l)-peripheral (19 pmol/l) ACTH gradient of 19.1 for the right IPS, conventionally suggestive of Cushing's disease. However, again, IPS ACTH level did not increase after CRH stimulation. Magnetic resonance imaging, while showing no evidence of an intrasellar tumour, revealed an 1.5 x 1.0 cm mass in the left sphenoid sinus which was initially interpreted as most probably being a mucosal polyp. After neurosurgical removal of the tumour, transient secondary adrenal insufficiency was present. The structure and immunostaining characteristics of the tumour demonstrated an ACTH cell adenoma of the pituitary. Ectopic ACTH-secreting pituitary adenomas may cause significant difficulties in differential diagnosis, localisation and appropriate therapy. Thus, although these tumours are rare, they should be included in the list of possible causes of ACTH-dependent Cushing's syndrome.
ACTH Syndrome, Ectopic↗
[Value of color-coded duplex ultrasound in evaluating arm blood vessels--arteries and hemodialysis shunts].
AIM: Comparison of colour coded duplex sonography (CCDS) to angiography in visualizing arteries and haemodialysis fistulas of the upper extremity. METHOD: 1145 arterial and vein segments were visualised using CCDS and angiography in 219 patients by different examiners with different degrees of experience. Sensitivity, specificity and accuracy were calculated. RESULTS: For the arterial segments--subclavian artery up to the distal lower arm arteries--the sensitivity was 90% and the specificity 99%. The sensitivity for the detection of vascular alterations in haemodialysis fistulas was 89% and the specificity 95%. CONCLUSION: CCDS may be able to replace diagnostic angiography of the arm except when evaluating the hand arteries and the central veins.
Adult↗