Do we need real-time MRI for diagnosis of temporomandibular joint disorders?

INTRODUCTION: Magnetic resonance imaging (MRI) has been approved as an appropriate radiological modality for temporomandibular joint (TMJ) diagnosis, whereas the results of international multicenter studies impressively show the limitations of static three-dimensional MRI. The state of the art for dynamic imaging of the TMJ in real-time are TrueFISP sequences in one sagittal plane. In order to support the diagnostics, a computer-assisted visualization procedure has been developed by the authors for both the static and dynamic MRI. METHODS: A number of validated sequences are available for the static 3D-MRI within the clinical routine. For dynamic MRI in real-time, True-FISP sequences in one sagittal plane with a slice thickness of 5-10 mm and 1.3 mm x 1.3 mm spatial resolution were applied. Both the dynamic and static MRI datasets are animated and visualized using the computer-assisted procedure. RESULTS: The computer-assisted procedure reliably supported the clinical diagnosis, especially the visibility of the articular disc was enhanced. On the basis of the static MRI, a 60-year-old patient was diagnosed with anterior disc displacement without reduction. In contrast, by the dynamic MRI, it was recognized how the articular disc was firstly somehow stretched and flattened before the mandibular condyle again glided under the disc, thus resulting in an anterior disc displacement with reduction. CONCLUSION: These results endorse the relevance of real-time diagnosis for the TMJ. The computer-assisted visualization has been approved as a reliable help for clinical diagnosis.

[Rare complication after Le Fort I osteotomy]. / Eine seltene Komplikation nach Le-Fort-I-Osteotomie.

Malfunctions of the eustachian tube after Le Fort I osteotomies are rare. A 22-year-old woman was treated by Le Fort I osteotomy for maxillary retrognathism. Postoperatively she developed recurrent tubal malfunction and middle ear effusions on the left side, with no improvement after adenotomy, tonsillectomy, and grommet insertion. In consecutive computed tomography and magnetic resonance imaging scans, a forward dislocation of the left pterygoid hamulus was demonstrated. In addition, damage to the tensor veli palatini muscle was evident. Both postoperative sequelae appear to be responsible for the unilateral tubal dysfunction.

Prospective evaluation of risk of vertebral fractures using quantitative ultrasound measurements and bone mineral density in a population-based sample of postmenopausal women: results of the Basel Osteoporosis Study.

OBJECTIVE: Prospective studies have shown that quantitative ultrasound (QUS) techniques predict the risk of fracture of the proximal femur with similar standardised risk ratios to dual-energy x-ray absorptiometry (DXA). Few studies have investigated these devices for the prediction of vertebral fractures. The Basel Osteoporosis Study (BOS) is a population-based prospective study to assess the performance of QUS devices and DXA in predicting incident vertebral fractures. METHODS: 432 women aged 60-80 years were followed-up for 3 years. Incident vertebral fractures were assessed radiologically. Bone measurements using DXA (spine and hip) and QUS measurements (calcaneus and proximal phalanges) were performed. Measurements were assessed for their value in predicting incident vertebral fractures using logistic regression. RESULTS: QUS measurements at the calcaneus and DXA measurements discriminated between women with and without incident vertebral fracture, (20% height reduction). The relative risks (RRs) for vertebral fracture, adjusted for age, were 2.3 for the Stiffness Index (SI) and 2.8 for the Quantitative Ultrasound Index (QUI) at the calcaneus and 2.0 for bone mineral density at the lumbar spine. The predictive value (AUC (95% CI)) of QUS measurements at the calcaneus remained highly significant (0.70 for SI, 0.72 for the QUI, and 0.67 for DXA at the lumbar spine) even after adjustment for other confounding variables. CONCLUSIONS: QUS of the calcaneus and bone mineral density measurements were shown to be significant predictors of incident vertebral fracture. The RRs for QUS measurements at the calcaneus are of similar magnitude as for DXA measurements.

[Stress-related vertical double vision and ptosis]. / Belastungsabhängige vertikale Doppelbilder und Ptosis. Diagnose: Okuläre Pseudomyasthenie bei Keilbeinmeningeom am Sinus cavernosus links.

A 43-year-old patient presented to our department because her left eyelid had exhibited drooping to varying extents for 2-3 months. Furthermore, in extreme positions or after rapid eye movement, she perceived diplopic images and was sensitive to light. The diagnosis of sphenoid meningioma was reached. Subsequently two rounds of radiopeptide therapy with (90)Y-DOTATOC (somatostatin analog) were administered within 3 months. This treatment approach led to a reduction of tumor volume in our patient as well as clinical improvement followed by stabilization.

A comprehensive classification of mandibular fractures: a preliminary agreement validation study.

This study evaluates a comprehensive classification system for mandibular fractures based on imaging analysis. The AO/ASIF scheme, defining three fracture types (A, B, C), three groups within each type (e.g. A1, A2, A3) and three subgroups within each group (e.g. A1.1, A1.2, A1.3) with increasing severity from A1.1 (lowest) to C3.3 (highest) was used. The mandible is divided into two vertical units (I and V), two lateral horizontal units (II and IV) and one central unit (III) comprising the symphyseal and parasymphyseal region. Type A fractures are non-displaced, type B are displaced and type C are multifragmentary/defect injuries. Groups and subgroups are further defined in the classification system. Two classification sessions using semi-automatic software with 7 and 9 surgeons were performed to evaluate 100 fracture cases in the first session and 50 in the second. Inter-observer reliability and individual rater's accuracy were evaluated by kappa coefficient and latent class analysis, respectively. The analysis of inter-observer agreement for the detailed coding showed kappa coefficients around 0.50 with higher agreement among raters in the vertical units. This system allows standardization of documentation of mandibular fractures, although improvement in the definition of categories and their application is required.

Hearing loss after discontinuing secondary prophylaxis for cryptococcal meningitis: relapse or immune reconstitution?

Relapse and immune reconstitution syndrome are difficult to distinguish in HIV-infected patients treated with antiretroviral therapy (ART). We report on a 26-year-old HIV-infected male (CDC C3) with hearing loss on the right side 2 months after discontinuing secondary prophylaxis for cryptococcal meningitis. CD4 cell counts had increased from 32/microl to stable counts > 200/microl for the preceding 6 months on ART but HIV replication was not fully suppressed (7,000 copies/ml). Magnetic resonance imaging identified lesions at the origin of the right cranial nerve VIII. Lumbar puncture revealed monocytic pleocytosis, slightly increased protein, but normal glucose and lactate levels, negative microbiological studies. Fluconazole was restarted and a new ART regimen was started in order to fully suppress HIV replication. Clinical and radiological signs were reversible during follow-up, and secondary prophylaxis was stopped after 6 months without adverse events. We review 26 published cases of cryptococcal infections with immune reconstitution syndrome and highlight the distinguishing features.

Focal myositis of the iliopsoas muscle--a benign pseudotumour: ultrasound appearance in correlation with CT and MRI.

OBJECTIVE: Focal myositis of the iliopsoas muscle is a rare condition. A case is presented, emphasizing the value of ultrasound for detection, localisation, image-guided biopsy and follow-up in correlation with CT and MRI findings. MATERIAL AND METHODS: A 58-year-old woman was referred to our clinic with strong left sided inguinal pain, which radiated to the thigh and had lasted for four days. Ultrasound, CT and MRI were performed. Ultrasound-guided biopsy with histological correlation was obtained and US-follow-ups were available. RESULTS: CT showed an enlarged iliopsoas muscle on the left side without any focal pathology or enhancement. MRI revealed a sharpely delineated lesion, which was hypointense to muscle in fat-suppressed T1 w images with circumferential enhancement and showed a hyperintense appearance in T2 w images. Ultrasound displayed a polylobulated, inhomogeneous and hypoechoic tumour within the iliopsoas muscle. Ultrasound-guided biopsy was found to be compatible with myositis. After oral therapy with steroids, improvement could be documented by serial ultrasound follow-up as the size of the tumour was definitely regressing. CONCLUSION: Focal myositis of the iliopsoas muscle is a rare entity which may mimic a tumoural lesion. Imaging findings may not be conclusive, and US-guided biopsy is recommended to rule out a malignant mass. Ultrasound seems to be the most cost-effective method for diagnosis, image guided biopsy and follow-up.

Value of smear and PCR in bronchoalveolar lavage fluid in culture positive pulmonary tuberculosis.

At present, further investigations are needed in patients with suspected pulmonary tuberculosis (TB) and either negative sputum smear or without sputum. The aim of the present study was to analyse the yield of bronchoalveolar lavage fluid (BALF) smear and PCR in patients with confirmed pulmonary TB. Patients with a positive culture for Mycobacterium tuberculosis complex in sputum or BALF were analysed over 5 yrs. In total, 90 out of 230 (39%) patients with culture-positive pulmonary TB had a positive sputum smear, and 120 patients underwent bronchoscopy. BALF smear was positive in 56 (47%), BALF PCR in 93 (78%) patients, and BALF smear and/or PCR was positive in 83%. In total, 71 patients who underwent bronchoscopy and had complete clinical records were further analysed. BALF (smear or Mycobacterium tuberculosis complex-PCR) allowed a rapid diagnosis in 10 (59%) out of 17 patients who had a negative sputum smear, and 49 (91%) out of 54 patients without sputum production. Of these 71 patients, 12 (17%) were only culture positive. Rapid diagnosis of pulmonary TB by smear and/or PCR was made in 190 out of 210 patients (90%) in sputum or BALF. In conclusion, combined use of bronchoalveolar lavage fluid smear and Mycobacterium tuberculosis complex-PCR has a good diagnostic yield in patients with sputum smear-negative tuberculosis or without sputum production.

Life-threatening orolingual angioedema during thrombolysis in acute ischemic stroke.

BACKGROUND: Orolingual angioedema can occur during thrombolysis with alteplase in stroke patients. However, data about its frequency, severity and the significance of concurrent use of angiotensin-converting-enzyme inhibitors (ACEi) are sparse. OBJECTIVE: (1), to alert to the potentially life-threatening complication of orolingual angioedema. (2), to present CT-scans of the tongue which exclude lingual hematoma. (3), to estimate the frequency of orolingual angioedema. (4), to evaluate the risk associated with the concurrent use of ACEi. METHODS: Single center, databank-based observational study on 120 consecutive patients with i. v. alteplase for acute stroke. Meta-analysis of all stroke studies on alteplase-associated angioedema, which provided detailed information about the use of ACE-inhibitors. Across studies, the Peto odds ratio of orolingual angioedema for "concurrent use of ACEi" was calculated. RESULTS: Orolingual angioedema occurred in 2 of 120 patients (1.7%, 95% CI 0.2-5.9 %). Angioedema was mild in one, but rapidly progressive in another patient. Impending asphyxia prompted immediate intubation. CT showed orolingual swelling but no bleeding. One of 19 (5%) patients taking ACEi had orolingual angioedema, compared to 1 of 101 (1%) patients without ACEi. Medline search identified one further study about the occurrence of alteplase-associated angioedema in stroke patients stratified to the use of ACEi. Peto odds ratio of 37 (95 % CI 8-171) indicated an increased risk of alteplasetriggered angioedema for patients with ACEi (p <0.001). CONCLUSION: Orolingual angioedema is a potentially life-threatening complication of alteplase treatment in stroke patients, especially in those with ACEi. Orolingual hematoma as differential diagnosis can be excluded by CT-scan.

Colonic involvement in non-necrotizing acute pancreatitis: correlation of CT findings with the clinical course of affected patients.

The purpose of this study was to describe CT findings of colonic involvement in acute non-necrotizing pancreatitis and to analyze the correlation between colonic wall thickening at CT and the clinical course of these patients. The CT examinations of 19 consecutive patients with acute non-necrotizing pancreatitis who were not treated with antibiotics initially were analyzed retrospectively. The severity of acute pancreatitis was categorized according to the CT severity index (CTSI) and the presence of colonic wall thickening at the initial CT was compared with the clinical course of all patients. Seven of 11 patients with a CTSI of 4 showed a colonic wall thickening, whereas the remaining patients with a CTSI of 4 (n=4), CTSI of 3 (n=5), and CTSI of 2 (n=3) showed no colonic abnormalities at CT. Patients with colonic wall thickening presented more often with fever, showed higher levels of infectious parameters, needed more often antibiotic therapy, and had more requests for additional CT examinations and CT-guided fluid aspirations as well as a longer duration of hospital stay as compared with patients without colonic wall involvement, even if the latter presented with the same CTSI initially. It is well known that translocation of the colonic flora may significantly influence the clinical course of patients with acute pancreatitis, and our results indicate that patients with acute pancreatitis who present with colonic wall thickening at CT have an increased risk for a complicated clinical course regarding systemic infection.

Dynamic time-resolved contrast-enhanced two-dimensional MR projection angiography of the pulmonary circulation: standard technique and clinical applications.

OBJECTIVE: Time-resolved pulmonary two-dimensional MR projection angiography is a fast acquisition technique that allows the generation of dynamic projection angiograms by a method similar to that used to generate digital subtraction angiograms. MR images are obtained after subtracting the mask defined at the beginning of the sequence from later images, thus generating time-resolved continuous projection angiograms that depict the passage of a bolus through the pulmonary circulation. This article describes the application of this novel technique in three patients with pathologic conditions not previously described with this modality and two control subjects. CONCLUSION: The analysis of the findings on dynamic time-resolved contrast-enhanced two-dimensional MR projection angiography shows that this technique is useful not only in revealing morphologic changes associated with pulmonary disorders but also in following the passage of the bolus through the cardiopulmonary circulation. The latter capability allows qualitative detection of normal or abnormal pathways and thus is potentially of value in the assessment of several pulmonary disorders.

Athletes with lower limb ischaemia.

The case of a young healthy sportsman and acute exacerbation of chronic infragenicular pain is presented. Further investigation revealed an obstruction of the tibiofibular trunk due to an osteochondroma, arising from the fibula, which was immediately resected. Osteochondroma is observed in 1-2% of the population and may present with vascular complications. In young patients and athletes, leg pain may be of vascular origin due to an entrapment or compression and should always be considered.

[Percutaneous stereotactic biopsy of non-palpable breast lesions using the Advanced Breast Biopsy Instrumentation (ABBI) system: critical evaluation of indication strategies]. / Perkutane stereotaktische Biopsie nicht palpabler Mammaläsionen mit dem Advanced Breast Biopsy Instrumentation (ABBI) System: Kritische Evaluation der Indikationsstellung.

PURPOSE: To compare the indications for biopsy with and without the use of the Breast Imaging Reporting and Data System. MATERIAL AND METHODS: Biopsies using the ABBI were performed in 62 patients with 64 non-palpable evident mammographic lesions. The initial decision for biopsy was made by non-radiologists due to suspicious microcalcifications (n = 53) and masses (n = 11). The indication was retrospectively reassessed by adopting the BI-RADS classification by three radiologists in consensus. The positive predictive value (PPV) of both indication strategies was assessed and compared. RESULTS: Biopsies adopting ABBI were performed without major side-effects and were diagnostic. Carcinoma was present in 14 lesions: nine specimens were diagnosed as DCIS and five as invasive carcinomas. For the 50 benign lesions histology revealed mastopathies (26/50) and fibroadenomas (8/50) as the most frequent diagnosis. The positive predictive value (PPV) for the initial indication was 22%, whereas PPV for BI-RADS based indications (categories 4 and 5) was 31%. CONCLUSION: ABBI enables stereotactically-guided procedures that result in representative and diagnostic biopsies. Standardized criteria like BI-RADS improve the PPV and should be a mandatory part of mammographic evaluation. Radiologists should remain involved in the decision making.

Ultrasound demonstration of mammographically detected microcalcifications.

PURPOSE: To evaluate the capabilities of breast ultrasound (US) for identifying microcalcifications in benign breast changes, in situ carcinomas, and small nonpalpable invasive carcinomas. MATERIAL AND METHODS: Forty-six consecutive patients with 49 clustered microcalcifications detected by mammography were included in this prospective study. Patients with palpable breast lesions were excluded. Breast US was performed with knowledge of mammographic findings for presence and visibility of microcalcifications, and for parenchymal structure abnormalities. Mammographic and US findings were compared with histology. RESULTS: Nine ductal in situ carcinomas, 2 lobular in situ carcinomas, 11 invasive carcinomas and 27 benign lesions were confirmed by histology. For all lesions, US achieved a sensitivity of 75% in the detection of microcalcifications. The detection rate for microcalcification in invasive and in situ carcinomas was 100%. In 11 cases, no microcalcifications were visible on US; they all proved to be benign on histology. CONCLUSION: Microcalcifications in malignant lesions are reliably recognized by US. They are, however, difficult to detect in fibrocystic breast changes.

[Radiology of gastrointestinal stromal tumors (GIST) and a case of Carney syndrome]. / Radiologie des gastrointestinalen Stromatumors (GIST). Gleichzeitig ein Beitrag zum Carney-Syndrom.

Gastrointestinal stromal tumors (GIST) represent an extremely rare group of tumors, which are mostly of smooth muscle origin like leiomyomas, leiomyosarcomas and leiomyoblastomas. With the introduction of immunohistochemical analysis an epithelioid and an autonomic nerve variant can be distinguished. The purpose of this review is to demonstrate the image morphological appearance of these rare tumors together with the pathology based upon a retrospective analysis of five of our own cases since 1997. There are no pathognomonic imaging findings for characterizing a gastrointestinal stromal tumor; however, it should be included in the differential diagnosis if one or multiple large, round or oval, well-delineated gastrointestinal tumors occur in combination with central necrosis. Carney's syndrome is characterized by the syndromal association of a gastrointestinal stromal tumor (originally: gastric leiomyosarcoma) with an extra-adrenal paraganglioma and a pulmonary chondroma. In this rare syndrome, the radiological approach is important to diagnose or rule out the--simultaneous or consecutive--appearance of at least two of the three tumor entities (GIST, extra-adrenal paraganglioma, pulmonary chondroma).

Magnetic resonance diagnosis of the anterior labrum and capsule. Effect of field strength on efficacy.

RATIONALE AND OBJECTIVES: The authors compare the performance of high-field and low-field magnetic resonance (MR) systems in the evaluation of shoulder instability, 35 patients were examined at field strengths of 1.0 T and of 0.2 T. METHODS: Surface coils were used in both systems. Because arthroscopy was used as gold standard, a preselected patient-population was obtained for the study. RESULTS: The sensitivity/specificity/accuracy of MR images acquired at 1.0 T for labrum pathology were 91%/67%/91% and 70%/80%/71% for the capsular complex. Compared with the above, the sensitivity/specificity/accuracy for 0.2 T MR images revealed 91%/67%/91% for the labrum pathology and 63%/80%/66% for the capsular complex respectively. In the evaluation of capsular lesions a comparison between the 0.2 T MR system and the 1.0 T system indicated a higher sensitivity and accuracy for the high-field images. Concerning labral lesions, the sensitivity and accuracy of the 0.2 T MR imager and the 1.0 T imager were comparable. CONCLUSIONS: Given differences in imaging protocols, imaging at 0.2 T does not adversely affect the assessment of shoulder instability when compared with imaging at 1.0 T. These preliminary results warrant more extensive clinical comparison of results obtained at different magnetic field strengths.

Mycotic aneurysm rupture of the descending aorta.

A 69-year-old diabetic male with salmonella bacteremia developed hypovolemic shock and swelling of the neck. A CT examination revealed massive mediastinal hemorrhage extending into the neck soft tissues caused by false aneurysm rupture of the descending thoracic aorta. Aortography showed continuous extravasation from a large leak at the medial side of the descending thoracic aorta. Although surgical intervention was immediately performed, the patient died 3 weeks later from multiple-organ failure. In this report, CT and angiographic findings of mycotic aneurysm rupture are presented and a review is given.

[Mandibular osteomyelitis after mandibular conduction anesthesia]. / Unterkieferosteomyelitis nach Mandibularisleitungsanästhesie.

Several complications following a mandibular nerve block were reported in the literature. In some cases pterygomandibular abscess formation may be caused by mandibular needle injections. There is no report of odontogenic osteomyelitis of the ascending mandibular ramus in the literature. Here two patients with osteomyelitis of the ascending ramus following a mandibular nerve block injection are presented.