Diagnostic imaging modalities in head and neck disease.

BACKGROUND: Because of the complex anatomy of the head and neck region, conventional projection radiography alone is unreliable and carries a high risk of misdiagnosis. The poor risk-benefit ratio of conventional radiography has led to their replacement by tomographic imaging for nearly all studies in this region. METHOD: This review is based on pertinent articles retrieved by a selective search in the PubMed database (January 1980 to May 2013) as well as on the relevant guidelines from Germany and abroad. RESULTS: The indication for diagnostic imaging in the anatomically complex head and neck region should be established for a specific type of imaging study on the basis of a thorough clinical examination. Conventional films, though easy to obtain, often cannot answer the diagnostic question and may yield confusing information leading to misdiagnosis. Computed tomography (CT) has the best risk-benefit profile and a high diagnostic value, but low-dose protocols have not yet been put into use in all centers. Magnetic resonance imaging (MRI) is best for bone and soft-tissue diagnosis, but consumes more resources. Digital volume tomography (DVT) is another type of three-dimensional, sectional imaging with high local resolution; the associated radiation exposure and image quality are generally both low, but may vary depending on the apparatus used. DVT cannot be used to evaluate the soft tissues. Ultrasonography can be used to evaluate superficial structures in the head and neck region; nuclear imaging can be used to evaluate thyroid disease and cancer. CONCLUSION: Inflammatory, traumatic, and neoplastic diseases of the head and neck are best evaluated with cross-sectional imaging (CT, MRI) in accordance with current guidelines. Conventional x-rays should, in general, only be used for dental evaluation, with rare exceptions.

Minimally invasive application of thrombin in the treatment of pseudoaneurysms following open aortic surgery.

BACKGROUND: Anastomotic leaks are uncommon complications following aortic surgery. To avoid the morbidity associated with a second surgical procedure, minimally invasive techniques have become increasingly popular. PURPOSE: To evaluate the feasibility and safety of thrombin in interventional treatment of postoperative pseudoaneurysms. MATERIAL AND METHODS: CT-guided percutaneous injection was chosen in four cases. Endovascular access using an occlusion balloon catheter placed in the orifice of the pseudoaneurysm was utilized in one case. RESULTS: The average volume of all pseudoaneurysms was 178 ± 190 mL with a volume of the patent lumen of 25 ± 28 mL. All aneurysms thrombosed after injection of 600 ± 237 IU of thrombin. During the follow-up period of an average of 10 months all pseudoaneurysms remained occluded. CONCLUSION: Our series demonstrates the feasibility of thrombin in the treatment of aortic anastomotic pseudoaneurysms. In combination with occlusion balloon catheters, even wide-necked pseudoaneurysms may be treated successfully. However, further investigations are warranted.

The relation of regional cerebral perfusion and atrophy in mild cognitive impairment (MCI) and early Alzheimer's dementia.

The spatial and temporal relations between regional cerebral blood flow (rCBF) and brain volume (rVOL) changes in incipient and early Alzheimer's dementia (AD) are not fully understood. The participants comprised 30 subjects with mild cognitive impairment (MCI) and 15 with mild AD who were examined using structural and perfusion-weighted magnetic resonance imaging (MRI) at 1.5 Tesla. Hippocampus and amygdala volumes were measured by manual volumetry. A region-of-interest co-localisation method was used to calculate rCBF values. DNA samples were genotyped for apolipoprotein E (APO E). In comparisons of AD with MCI, rCBF was reduced in the posterior cingulum only, while profound rVOL reductions occurred in both right and left amygdala and in the right hippocampus, and as a trend, in the left hippocampus. Brain volumes of the hippocampus and the amygdala were uncorrelated with the respective rCBF variables in both MCI and AD. Hippocampal but not amygdalar volumes were associated with presence of one or two APOE epsilon4 alleles in MCI and mild AD, while there was no association of APOE epsilon4 allele with rCBF. These data support earlier indications that rCBF and rVOL changes are at least partly dissociated in the early pathogenesis of AD and heterogeneously associated with the APOE risk allele. The data also support the concept of functional compensatory brain activation and the diaschisis hypothesis as relevant in incipient and early AD.

Voxel-based analyses of magnetization transfer imaging of the brain in hepatic encephalopathy.

AIM: To evaluate the spatial distribution of cerebral abnormalities in cirrhotic subjects with and without hepatic encephalopathy (HE) found with magnetization transfer imaging (MTI). METHODS: Nineteen cirrhotic patients graded from neurologically normal to HE grade 2 and 18 healthy control subjects underwent magnetic resonance imaging. They gave institutional-review-board-approved written consent. Magnetization transfer ratio (MTR) maps were generated from MTI. We tested for significant differences compared to the control group using statistical non-parametric mapping (SnPM) for a voxel-based evaluation. RESULTS: The MTR of grey and white matter was lower in subjects with more severe HE. Changes were found in patients with cirrhosis without neurological deficits in the basal ganglia and bilateral white matter. The loss in magnetization transfer increased in severity and spatial extent in patients with overt HE. Patients with HE grade 2 showed an MTR decrease in white and grey matter: the maximum loss of magnetization transfer effect was located in the basal ganglia [SnPM (pseudo-)t = 17.98, P = 0.0001]. CONCLUSION: The distribution of MTR changes in HE points to an early involvement of basal ganglia and white matter in HE.

Surgical management of retropharyngeal abscesses.

CONCLUSION: Retropharyngeal abscess (RPA) is a rare, potentially life-threatening disease, requiring appropriate otorhinolaryngologic as well as radiologic diagnostics, and medical and surgical intervention by a transoral, transcervical or transnasal approach in a multidisciplinary setting. OBJECTIVES: The risks and benefits of surgical intervention in patients with RPA were assessed. The main outcome measure was the clinical resolution of the abscess. PATIENTS AND METHODS: A retrospective chart review was performed at a tertiary care university hospital over a period of 28 months. Eleven patients aged 1 to 68 years with the diagnosis of RPA were included. RESULTS: All patients presented with restricted cervical mobility and all patients had CT and/or MRI scan on admission. The mean abscess volume was 9.4 cm(3). Surgical intervention was performed in all cases, including transoral (n=5), transcervical (n=3) or combined transoral and transcervical (n=2) drainage. In one patient RPA close to the skull base was drained by an MRI-guided transnasal approach. All patients recovered; however, there was one recurrence and in one case surgical tracheotomy was unavoidable during the course of disease. Growth of streptococcal species was verified in six of the examined abscesses. Abscessing lymphadenitis, infection of a cervical cyst, and previous ganglionar local opioid analgesia treatment were identified as causative factors.

Leser-Trélat sign presenting in a patient with ovarian cancer: a case report.

INTRODUCTION: Seborrheic keratoses are very common findings in elderly patients. However, a sudden onset and dramatic increase in the number and size of these benign lesions deserves special attention, since this may represent the Leser Trélat sign, a rare paraneoplastic cutaneous syndrome. CASE PRESENTATION: A 92-year-old female presented to our clinic with multiple eruptive seborrheic keratoses, which had dramatically increased in size and number over the past two years. A diagnostic work-up revealed an ovarian carcinoma. Hence, cutaneous findings in our patient were consistent with the diagnosis of the Leser-Trélat sign. CONCLUSION: The Leser-Trélat sign may coincide with the diagnosis of occult cancer or follow or precede it by months or years. Practitioners should take cases of eruptive seborrheic keratoses seriously and perform thorough patient examinations.

Myocardial delayed contrast enhancement in patients with arterial hypertension: initial results of cardiac MRI.

PURPOSE: In arterial hypertension left ventricular hypertrophy comprises myocyte hypertrophy, interstitial fibrosis and structural alterations of the coronary microcirculation. MRI enables the detection of myocardial fibrosis, infarction and scar tissue by delayed enhancement (DE) after contrast media application. Aim of this study was to investigate patients with arterial hypertension but without known coronary disease or previous myocardial infarction to detect areas of DE. METHODS AND MATERIAL: Twenty patients with arterial hypertension with clinical symptoms of myocardial ischemia, but without history of myocardial infarction and normal coronary arteries during coronary angiography were investigated on a 1.0 T superconducting magnet (Gyroscan T10-NT, Intera Release 8.0, Philips). Fast gradient-echo cine sequences and T2-weighted STIR-sequences were acquired. Fifteen minutes after injection of Gadobenate dimeglumine inversion recovery gradient-echo sequences were performed for detection of myocardial DE. Presence or absence of DE on MRI was correlated with clinical data and the results of echocardiography and electrocardiography, respectively. RESULTS: Nine of 20 patients showed DE in the interventricular septum and the anteroseptal left ventricular wall. In 6 patients, DE was localized intramurally and in 3 patients subendocardially. There was a significant correlation between myocardial DE and ST-segment depressions during exercise and between DE and left-ventricular enddiastolic pressure. Patients with intermittent atrial fibrillation showed a myocardial DE more often than patients without atrial fibrillation. CONCLUSION: In our series, 45% of patients with arterial hypertension showed DE on cardiac MRI. In this clinical setting, delayed enhancement may be due to coronary microangiopathy. The more intramurally localization of DE, however, rather indicates myocardial interstitial fibrosis.

Detection of changed regional cerebral blood flow in mild cognitive impairment and early Alzheimer's dementia by perfusion-weighted magnetic resonance imaging.

The utility of perfusion-weighted magnetic resonance imaging (PW-MRI) for detecting changes in regional cerebral blood flow (rCBF) in patients with mild cognitive impairment (MCI) and early Alzheimer's disease (AD) was evaluated. Thirteen cognitively normal (CN) elderly subjects, 35 mostly amnestic MCI subjects and 20 subjects with mild probable AD were enrolled. During i.v. injection of gadopentetate dimeglumine, a dynamic T2*-weighted single-shot EPI sequence was conducted using a 1.5-T scanner. Frontobasal (FROB), temporoparietal (TPAR), mesiotemporal (MTMP), anterior and posterior cingular (ACING, PCING), amygdala (AMYG), thalamus and cerebellar brain regions were studied. rCBF was computed from regional cerebral blood volume and arterial input function and normalised to white matter. Images were analysed by manually placed regions of interest using anatomical coregistration. Significant decreases of rCBF were detected in MCI vs. CN in MTMP (-23%), AMYG (-20%) and ACING (-15%) with no further decline in mild AD. In PCING hypoperfusion (-10%) was confined to AD. These hypoperfusional changes are a possible correlate of localised impairment of CNS function. In FROB no perfusion changes were observed between diagnostic groups, but hyperperfusion was observed in mild dementia stages, possibly reflecting functional compensatory mechanisms. These data suggest that PW-MRI detects specific changes in rCBF not only in AD, but also in amnestic MCI, a disorder suggested to largely represent a pre-dementia stage of AD. This method may thus be useful in both research and clinical applications to detect early functional brain changes in the pathogenesis of dementias.

IFN-alpha skews monocytes into CD56+-expressing dendritic cells with potent functional activities in vitro and in vivo.

The antitumor effect of IFN-alpha is mediated by the activation of CTLs, NK cells, and the generation of highly potent Ag-presenting dendritic cells (IFN-DCs). In this study, we show that IFN-DCs generated in vitro from monocytes express CD56 on their surface, a marker which has been thought to be specific for NK cells. FACS analyses of CD56(+) and CD56(-) IFN-DCs showed a nearly identical pattern for most of the classical DC markers. Importantly, however, only CD56(+) IFN-DCs exhibited cytolytic activity up to 24% that could almost completely be blocked (-81%) after coincubation with anti-TRAIL. Intracytoplasmatic cytokine staining revealed that the majority of IFN-DCs independently of their CD56 expression were IFN-gamma positive as well. In contrast, CD56(+) IFN-DCs showed stronger capacity in stimulating allogenic T cells compared with CD56(-) IFN-DC. Based on these results, five patients with metastasized medullary thyroid carcinoma were treated for the first time with monocyte-derived tumor Ag-pulsed IFN-DCs. After a long term follow-up (in mean 37 mo) all patients are alive. Immunohistochemical analyses of delayed-type hypersensitivity skin reaction showed a strong infiltration with CD8(+) cells. In two patients no substantial change in tumor morphology was detected. Importantly, by analyzing PBMCs, these patients also showed an increase of Ag-specific IFN-gamma-secreting T cells. In summary, we here describe for the first time that cytotoxic activity of IFN-DCs is mainly mediated by an IFN-DC subset showing partial phenotypic and functional characteristics of NK cells. These cells represent another mechanism of the antitumor effect induced by IFN-alpha.

Minimally invasive therapy of pseudoaneurysms of the trunk: application of thrombin.

Thrombin injection has been proven to be successful in postcatheterization pseudoaneurysms. However, there are only a few reports on the treatment of pseudoaneurysms of the trunk. We report our first experiences using a percutaneous as well as an endovascular access. Eight iatrogenic pseudoaneurysms of the trunk (aorta, n = 4; pulmonary artery, n = 1; gastroduodenal artery, n = 1; left gastric artery, n = 1, renal artery, n = 1) were treated either percutaneously using CT guidance (n = 3) or via an endovascular access (n = 5). Noninvasive control angiograms were performed at day 1 and weeks 1 and 3 by either CT or MR angiography. The total volume of the pseudoaneurysms was 31.2 +/- 23.1 ml on average, with a mean volume of the perfused aneurysmal lumen of 12.9 +/- 7.2 ml. The maximum diameter was 4.1 +/- 1.39 cm on average. In each case, the aneurysmal neck was not wider than 2 mm. One pseudoaneurysm occluded spontaneously following selective catheterization. The remaining pseudoaneurysms were successfully treated by injection of 765 +/- 438.1 IU thrombin. In one individual, a nontarget embolization occurred, as well as an intervention-associated rupture of a pseudoaneurysm. High-grade stenoses of the donor artery were found in a different case. Only once was the endoluminal access converted to a percutaneous one. Thrombin injection might be a future first-line treatment of vascular lesions such as pseudoaneurysms of the trunk. In our experience both percutanous and endoluminal access are technically feasible and safe. However, further experiences are mandatory, especially concerning the question of dosage and long-term results.

Comparison of whole-body 64-slice multidetector computed tomography and conventional radiography in staging of multiple myeloma.

This study compares the sensitivity of whole-body multidetector CT (MDCT) and conventional radiography (CR) in the staging of multiple myeloma (MM). Twenty-nine patients with MM underwent a staging examination both by MDCT and CR. CT examination was performed with a collimation of 64x0.6 mm, a tube potential of 100 kVp, an effective tube current-time product of 100 mAs and automatic dose modulation as low-dose protocol. Number, size and diagnostic confidence of osteolytic lesions were determined and compared. The effective dose of MDCT and CR was assessed. Using MDCT, the detection of osteolysis was increased seven-fold concerning the spine. Ninety-seven lesions in 18 patients were detected exclusively by MDCT. The detection rate concerning the spine, pelvic skeleton and thoracic cage was significantly higher (p< or =0.001), and diagnostic confidence was increased by MDCT (p<0.02) compared to CR. Therapy was changed after MDCT in 18.2% of the patients with a clinical suspicion of progressive disease. The estimated effective dose of MDCT (4.8 mSv) and CR (1.7 mSv) was comparable. In conclusion, MDCT has a significantly higher sensitivity and reliability in the detection of osteolysis than CR and can be recommended as standard imaging method in the staging of MM.

Identification of occult metastases of medullary thyroid carcinoma by pentagastrin-stimulated intravenous calcitonin sampling followed by targeted surgery.

BACKGROUND: High calcitonin (CT) serum levels suggest metastatic spread in medullary thyroid carcinoma (MTC) after thyroidectomy. In limited disease stages, however, morphological investigations including ultrasound, magnetic resonance imaging (MRI) and 18F-FDG positron emission tomography ([18F]FDG-PET) may often fail to identify exact tumour sites. OBJECTIVE: The aim of the present study was to establish an improved strategy to identify small cervical tumours by combining pentagastrin stimulation with bilateral cervical intravenous CT sampling followed by high-resolution ultrasound. DESIGN AND PATIENTS: Six MTC patients were examined, of whom five patients already had bilateral neck dissection. Five patients had sporadic MTC, and one patient suffered from MEN2a. RESULTS: Retrospective analysis of all patients revealed a highly sensitive positive correlation between an early calcitonin peak (20-40 s after pentagastrin injection) and site of cervical tumour affection. Postinterventional ultrasound examination of the affected regions of the neck revealed suspicious presence; in some cases small lymph nodes of less than 1 cm in size were then surgically excised. On histology, small tumours could be identified in four patients. Postsurgical examination revealed a clear decline of basal serum calcitonin levels in four patients (between -41% and -100%). In two patients CT normalized to baseline levels (< 10 pg/ml) and in another two patients CT rendered to near normal (14 and 17 pg/ml). CONCLUSION: Pentagastrin stimulation-based intravenous catheter sampling may be beneficial in the diagnostic work-up of MTC after thyroidectomy. Our data show that an early calcitonin peak (20-40 s after administration of pentagastrin) helps to identify tumour-affected regions.

Wilson's disease tremor is associated with magnetic resonance imaging lesions in basal ganglia structures.

Wilson's disease (WD) is an inherited disorder of copper metabolism yielding marked motor deficits, including a severely disabling tremor. As a structural correlate of the disease, a variety of cerebral abnormalities has been revealed. However, the relationship between motor deficits and cerebral lesions has remained largely unknown. Here, we investigated correlation between WD tremor and cerebral magnetic resonance imaging (MRI) findings. Cerebral MRI abnormalities in 6 symptomatic WD patients were compared to findings in 6 asymptomatic WD patients and 10 healthy controls. All patients were treated with long-term copper chelating therapy. Motor symptoms including tremor were determined by Unified Parkinson's Disease Rating Scale Part III (UPDRS-III). MRI findings in symptomatic WD patients revealed significant symmetric T2*-weighted hypointense signal alterations of globus pallidus, head of the caudate nucleus, and substantia nigra. In contrast, MRI of asymptomatic WD patients did not differ from healthy controls. Correlation analysis revealed a significant positive correlation between MRI basal ganglia lesions and UPDRS action tremor score. Our results demonstrate for the first time that Wilson's disease tremor is associated with lesions of the globus pallidus, the head of the caudate nucleus, and the substantia nigra.

Multi-detector CT-colonography in inflammatory bowel disease: prospective analysis of CT-findings to high-resolution video colonoscopy.

AIM: Prospective analysis of multi-detector CT-colonography (MDCTC) in patients with inflammatory bowel disease (IBD) compared to high-resolution video-endoscopy (HRVC). MATERIALS AND METHODS: Twenty-one patients (mean age 49.6 years) with Crohn's disease or ulcerative colitis underwent MDCTC (Somatom Volume Zoom, Siemens, Erlangen; 1mm collimation, Pitch 8, 100 mAs, 120 kVp). HRVC was performed within 2 h after MDCTC. MDCTC was analyzed by two blinded readers. MDCTC-findings including bowel wall alterations and extraintestinal changes were compared to results of HRVC. RESULTS: Over-all-sensitivity was 100% for endoluminal lesions with correct diagnosis of two cancers. Acute and chronic IBD were correctly identified by MDCTC in 63.6%, and 100%, respectively, with a specificity of 75%, and 100%. Sensitivity, specificity, positive and negative predictive values of MDCTC for diagnosis of acute and chronic disease were best for chronic disease. Sensitivity was worst for acute ulcerative colitis and specificity was worst for acute Crohn's disease. Haustral loss was seen only in ulcerative colitis. Pseudopolyps and fistulae were findings exclusive to Crohn's disease. Particularly extraintestinal findings as increased vascularization and local lymphadenopathy correlated well with endoscopic definition of acute disease. Because of the possibly more vulnerable colonic wall in acute inflammatory bowel disease, the air inflation for MDCTC should be performed most carefully to avoid any risk of colonic perforation. CONCLUSION: MDCTC may help to distinguish between patients with acute and chronic IBD. Especially extraintestinal complications, tumorous as well as pseudo-tumorous lesions can be detected with high sensitivity and specificity.

Recurrent embolism in the course of marantic endocarditis.

Marantic or nonbacterial thrombotic endocarditis (NBTE) associated with systemic embolism is usually a complication of advanced or terminal malignancies. We report on the case of a 46-year-old woman in whom nonbacterial thrombotic endocarditis (NBTE)-related cerebral embolism was the first clinical sign of ovarian neoplasm, which was diagnosed after cardiac surgery. Marantic endocarditis should alert the physician to make every effort to diagnose the possible background of this clinical phenomenon. Early identification of NBTE, treatment of the underlying disease, and the associated coagulopathy could possibly prevent cardiac surgery.