[Characteristics and applications of a flat panel computer tomography system]. / Eigenschaften und Anwendungen der Flächendetektor-basierten Volumen-Computertomographie.

PURPOSE: To assess a new flat panel volume computed tomography (FP-VCT) with very high isotropic spatial resolution as well as high Z-axis coverage. MATERIALS AND METHODS: The prototype of an FP-VCT scanner with a detector cell size of 0.2 mm was used for numerous phantom studies, specimen examinations, and animal research projects. RESULTS: The high spatial resolution of the new system can be used to accurately determine solid tumor volume, thus allowing for earlier assessment of the therapeutic response. In animal experimentation, whole-body perfusion mapping of mice is feasible. The high spatial resolution also improves the classification of coronary artery atherosclerotic plaques in the isolated post mortem human heart. With the depiction of intramyocardial segments of the coronary arteries, investigations of myocardial collateral circulation are feasible. In skeletal applications, an accurate analysis of the smallest bony structures, e. g., petrous bone and dental preparations, can be successfully performed, as well as investigations of repetitive studies of fracture healing and the treatment of osteoporosis. CONCLUSION: The introduction of FP-VCT opens up new applications for CT, including the field of molecular imaging, which are highly attractive for future clinical applications. Present limitations include limited temporal resolution and necessitate further improvement of the system.

[Feasibility of flat-panel volumetric computed tomography (fpVCT) in experimental small animal imaging of osteoporosis - initial experience]. / Erste Erfahrungen mit einem Flächendetektor-Volumen-CT (fpVCT) in der experimentellen Osteoporosediagnostik am Kleintiermodell.

BACKGROUND: Flat-panel volumetric computed tomography (fpVCT) is a new, noninvasive CT imaging modality with increased isotropic resolution. Technical details, potential applications, and our initial experience with a fpVCT prototype scanner in the imaging of osteoporosis in a rat model are presented. METHODS: To date, 21 rats have been investigated in vivo with fpVCT. Pharmacologic effects on bone mineral density (BMD) and structure were of special interest. Image evaluation focussed on the second lumbar vertebra and the left femoral bone. To validate measurement results, BMD values calculated with fpVCT were correlated with results of BMD measurements from ashing of the second lumbar vertebra and femoral bones. RESULTS: Our initial results show that fpVCT is capable of detecting differences in BMD between ovariectomized rats treated with estradiol and a control group with high statistical significance (p<0.05), corresponding to ashing as the gold standard. CONCLUSIONS: In a rat model, fpVCT imaging is especially useful in longitudinal in vivo investigations of BMD measures. Spatial resolution of up to 150 microm allows imaging of the trabecular structure only in human cadaveric bones.

[Value of MR-guided localization and biopsy in breast lesions]. / Stellenwert der MR-gestützten Lokalisation und Biopsie von Brustläsionen.

Contrast-enhanced dynamic MR mammography can provide important additional diagnostic information when performed for certain indications. When suspicious lesions are identified on MR mammography and cannot be reproduced using other imaging modalities, a decision must be made as to its management, i. e. further diagnostic work-up. One possibility is the short-term follow-up of such findings, resulting in higher costs and a possible delay in the start of treatment of a malignant lesion. An alternative to a follow-up is an MR-guided intervention. MR-compatible equipment has been developed for this purpose. This includes equipment specialized for percutaneous biopsy and preoperative localization. The following is an overview of the diagnostic value of MR-guided biopsy and preoperative localization including the relevant literature.

Extensive coronary thrombosis in thrombotic-thrombocytopenic purpura.

We describe a case of a 41-year-old female patient who was admitted with typical signs of thrombotic-thrombocytopenic purpura. Markers of myocardial ischemia (Troponin T, CK, CK-MB) were even present at admission without symptoms of angina pectoris. Only a few hours after admission the patient developed all signs of cardiogenic shock with subsequently cardiac arrest. Postmortal coronary angiographies showed occlusions in all coronary arteries with significant myocardial necrosis. We are unaware of any report that describes macrovascular occlusions in thrombotic-thrombocytopenic purpura.

Use of semiflexible applicators for radiofrequency ablation of liver tumors.

PURPOSE: To evaluate the feasibility and potential advantages of the radiofrequency ablation of liver tumors using new MRI-compatible semiflexible applicators in a closed-bore high-field MRI scanner. METHODS: We treated 8 patients with 12 malignant liver tumors of different origin (5 colorectal carcinoma, 2 cholangiocellular carcinoma, 1 breast cancer) under MRI guidance. Radiofrequency ablation (RFA) was performed using 5 cm Rita Starburst Semi-Flex applicators (Rita Medical Systems, Milwaukee, WI, USA) which are suitable for MR- and CT-guided interventions and a 150 W RF generator. All interventions were performed in a closed-bore 1.5 T high-field MRI scanner for MRI-guided RFA using fast T1-weighted gradient echo sequences and T2-weighted ultra-turbo spin echo sequences. Control and follow-up MRI examinations were performed on the next day, at 6 weeks, and every 3 months after RFA. Control MRI were performed as double-contrast MRI examinations (enhancement with iron oxide and gadopentetate dimeglumine). All interventions were performed with the patient under local anesthesia and analgo-sedation. RESULTS: The mean diameter of the treated hepatic tumors was 2.4 cm (+/-0.6 cm, range 1.0-3.2 cm). The mean diameter of induced necrosis was 3.1 cm (+/-0.4 cm). We achieved complete ablation in all patients. Follow-up examinations over a duration of 7 months (+/-1.3 months, range 4-9 month) showed a local control rate of 100% in this group of patients. All interventions were performed without major complications; only 2 subcapsular hematomas were documented. CONCLUSION: RFA of liver tumors using semiflexible applicators in closed-bore 1.5 T scanner systems is feasible. These applicators might simplify the RFA of liver tumors under MRI control. The stiff distal part of the applicator facilitates its repositioning.

[Potential advantages of the MRI for the radiofrequency ablation of liver tumors]. / Potenzial der MRT für die Radiofrequenzablation von Lebertumoren.

PURPOSE: To present first results of radiofrequency ablation of liver tumors using a new MR compatible applicator. MATERIALS AND METHODS: We performed 37 interventions in 20 patients (mean age 58.6 years) with primary intrahepatic malignancies or metastases: colorectal carcinoma n = 6, hepatocellular carcinoma n = 3, pancreatic carcinoma n = 4, sarcoma n = 2, cholangiocellular carcinoma n = 1, carcinoma of the tonsil n = 1, breast carcinoma n = 1, gastric carcinoma n = 1, and gastrointestinal stroma tumor n = 1. Interventions were performed under CT-guidance with CT fluoroscopy (n = 32) and under MR-guidance (n = 5) using fast T1-weighted sequences in breath-hold technique. RFA was performed with the RF-generator (150 W) under local anesthesia and sedation using MR compatible applicators (Starburst XL, Rita Medical Systems, USA) together with the appropriate Soft Tissue Introducer System. Intra-interventional control was performed with intrahepatically or intralesionally placed introducer system or applicator. MRI was performed with plain breath-triggered T2-weighted turbo spin echo sequences (TSE T2) with fat saturation. RESULTS: All interventions were performed without major events. The mean diameter of induced coagulation was 4.0 (+/- 0.7) cm. Repositioning was necessary in 8 interventions (21 %) after detection of residual tumor on an intra-interventional MRI. After a mean follow-up of 6.5 (+/- 1.2) months, the local tumor control rate was 92 %. CONCLUSION: MR-compatible RF applicators offer the opportunity for intra-interventional detection of residual tumor during RF ablations by use of sensitive MRI sequences. These procedures may lead to a higher confidence in tumour ablation and may reduce the number of re-interventions and local recurrences of intrahepatic tumors.

[Value of electron beam tomography (EBT)]. / Wertigkeit der Elektronenstrahl-Computertomographie (EBT) -- II. Nichtkardiale Anwendungen und Strahlenexposition.

Electron beam tomography (EBT) has been scientifically evaluated to a much lesser degree for non-cardiac indications than for cardiac purposes. Therefore, four groups of investigators in Berlin (2), Mannheim and Munchen, which were supported by the Deutsche Forschungsgemeinschaft (DFG), included applications outside the heart in their evaluation of EBT technology. EBT has proven useful to look for pulmonary embolism and to assess other vessels (aorta, aortic branches, and intracranial arteries). Imaging of the lung parenchyma benefits from its intrinsic high contrast and from the fast data acquisition of EBT. Limited photon efficiency, higher radiation exposure, increased noise levels and other artifacts, however, markedly reduce the value of EBT for imaging of low contrast objects compared to conventional spiral CT and multislice CT (MSCT), compromising, in particular, the morphologic depiction of parenchymal abdominal organs and the brain. Consequently, scientific studies to further evaluate EBT for scanning of the brain and parenchymal abdominal organs were not pursued. Radiation exposure for non-cardiac EBT studies is up to three times higher than that for respective spiral CT studies, and in children EBT can only be advocated in select cases. Radiation exposure for the various prospectively triggered cardiac examination protocols of EBT is lower than that for conventional coronary angiography. Radiation exposure in cardiac multislice CT exceeds severalfold that of EBT, but the dose efficiency of EBT and MSCT are similar due to higher spatial resolution and less image noise of MSCT. In addition, modifications of MSCT (ECG pulsing) can further reduce radiation exposure to the level of EBT. Technical improvements of the EBT successor scanner "e-Speed" enable faster data acquisition at higher spatial resolution. Within comparative studies, the "e-Speed" will have to prove its value and competitiveness, particularly in comparison with multislice CT. After profound scientific assessment in a multicenter evaluation supported by the Deutsche Forschungsgemeinschaft (DFG) and regardless of the specific suitability of electron beam tomography for various cardiac and some non-cardiac indications, the investigators unanimously find the electron beam tomograph Evolution C150 XP not suitable as a whole body CT scanner.

[Iodine delivery rate of different concentrations of iodine-containing contrast agents with rapid injection]. / Jodeinbringungsgeschwindigkeit verschieden konzentrierter Röntgenkontrastmittel bei schneller intravenöser Injektion.

PURPOSE: To determine how the concentration of iodinated contrast media for computed tomography studies affects the iodine delivery rate at various conditions. MATERIALS AND METHODS: Three nonionic, iodinated contrast agents that are marketed for computed tomography applications were administered through 1.1 and 1.3 mm large peripheral vein catheters into a vein phantom with room temperature and with pre-heating of the agents at 37 degrees C using a power injector. Each injection applied 40 ml of contrast medium at a flow rate of four to eight ml/s. The iodine concentration of Iopromide, Iomeprol, and Iodixanol varied between 300 and 400 mg iodine per cc. The power injector used a pressure limit of 21 bar. For each experiment, the maximum iodine deliver rate was calculated from the highest possible flow rate recorded. RESULTS: Larger vein catheters and the higher contrast temperature yielded the highest flow rates. With the higher iodine concentrations, viscosity limited the injection speed of the achievable pressure limit. The highest iodine delivery rate was 2560 mg/s, using an agent with 320 mg/ml iodine content. With the more concentrated agent, a maximal iodine delivery rate of 2400 mg/s was achieved. CONCLUSION: Very high iodinated contrast agent concentrations do not increase the iodine delivery rate of rapid peripheral intravenous injections, since the high viscosity of such agents causes the injection pressure to increase more than the higher iodine concentration would compensate for. With lower injection velocities, the higher viscosity of highly concentrated contrast agents may remain without practical consequences.

In vitro coronary artery imaging with sixteen-slice helical computed tomography.

PURPOSE: To determine the benefits of submillimeter coronary computed tomography (CT) angiography in vitro. MATERIAL AND METHODS: The coronary arteries of three domestic pigs were filled with contrast agent and depicted with clinically applicable CT angiography protocols with a slice thickness of 0.63 to 2.5 mm. RESULTS: With 2.5 mm slices, only the third-degree coronary artery branches could be discerned. With 1.25 mm slices, some fourth-degree branches of the right coronary artery could be discerned upon maximum intensity projections. With 0.63mm slices, fourth-degree coronary artery branches could be discerned in all locations. CONCLUSION: The introduction of 16-row detector CT with submillimeter z-axis resolution translates into an order-of-magnitude benefit for the depiction of coronary artery branches.

[Diagnostic value of electron-beam computed tomography (EBT). I. Cardiac applications]. / Diagnostische Wertigkeit der Elektronenstrahl-Computertomographie (EBT). I. Kardiale Anwendungen.

Electron beam tomography (EBT) directly competes with other non-invasive imaging modalities, such as multislice computed tomography, magnetic resonance imaging, and echocardiography, in the diagnostic assessment of cardiac diseases. EBT is the gold standard for the detection and quantification of coronary calcium as a preclinical sign of coronary artery disease (CAD). Its standardized examination protocols and the broad experience with this method favor EBT. First results with multislice CT indicate that this new technology may be equivalent to EBT for coronary calcium studies. The principal value of CT-based coronary calcium measurements continues to be an issue of controversy amongst radiologists and cardiologists due to lack of prospective randomized trials. Coronary angiography with EBT is characterized by a high negative predictive value and, in addition, may be indicated in some patients with manifest CAD. It remains to be shown whether coronary angiography with multislice CT is reliable and accurate enough to be introduced into the routine work-up, to replace some of the many strictly diagnostic coronary catheterizations in Germany and elsewhere. Assessment of coronary stent patency with EBT is associated with several problems and in our opinion cannot be advocated as a routine procedure. EBT may be recommended for the evaluation of coronary bypasses to look for bypass occlusions and significant stenoses, which, however, can be equally well achieved with multislice CT. Quantification of myocardial perfusion with EBT could not replace MRI or other modalities in this field. EBT has proven to be accurate, reliable and in some instances equivalent to MRI, which is the gold standard for the quantitative and qualitative evaluation of cardiac function. Some disadvantages, not the least of which is the limited distribution of electron beam scanners, favor MRI for functional assessment of the heart.

[Cost-utility analysis of contrast-enhanced MR angiography with automated table-translation for diagnosis and therapy planning in patients with peripheral vascular disease]. / Kosten-Nutzwert-Analyse der kontrastverstärkten MR-Angiographie mit automatischem Tischvorschub zur Diagnose und Therapieplanung bei peripherer arterieller Verschlusserkrankung.

PURPOSE: To analyze the cost-utility of contrast-enhanced MR angiography (ceMRA) in the diagnosis and the planning of surgical or interventional treatment in patients with peripheral arterial occlusive disease. MATERIALS AND METHODS: Additional costs and incremental costs per quality-adjusted life-year for ceMRA were calculated by a decision model. The costs of ceMRA and conventional angiography were compared. Treatment was either surgery or PTA. A retrospective analysis of 24 patients provided the data for the diagnostic accuracy of ceMRA. The data about quality of life assessment were taken from the literature. Costs were calculated in Euro using the current fee schedule. The influence of the individual parameters on the model was estimated from a sensitivity analysis. RESULTS: Per quality-adjusted life-year, ceMRA added euro; 24,408.60 in cases undergoing radiologic intervention and euro; 24,191.32 in cases treated surgically. CONCLUSION: Despite its high costs, ceMRA is an effective diagnostic procedure considering patient benefits. Additional costs do not exceed an acceptable range.

[Application of multislice detector spiral computed tomography to intracranial aneurysms: first clinical experience]. / Erste klinische Erfahrungen in der Anwendung der Mehrzeilen-Spiral-CT-Angiographie bei intrakraniellen Aneurysmen.

PURPOSE: To identify advantages when using the new multislice spiral CT technology (MSCT) for the detection and demonstration of intracranial aneurysms with CT angiography (CTA)? MATERIAL AND METHODS: Patients with suspected intracranial aneurysms underwent 4- and 8-slice spiral CTA. Image postprocessing included "maximum intensity projection" (MIP),"volume rendering" (VR) and additionally curved multiplanar reconstructions (MPR) for aneurysms suspected at the carotid siphon. The results were compared with those achieved with digital subtraction angiography (DSA). RESULTS: In 19 patients 21 out of 22 aneurysms were detected by CTA. A high resolution three-dimensional view of the aneurysm morphology in spatial relation to the surrounding structures was achieved. Further information could be gained by making a detailed examination of the inside wall of the aneurysm, using virtual vascular 3D-endoscopy and virtual 3D-craniotomy. CONCLUSION: Compared to DSA,MS-CTA is a useful additional and in selected cases alternative modality for the detection with marked advantages in the demonstration of intracranial aneurysms.

Detection of myocardial ischemia by electron beam CT. Experimental studies.

PURPOSE: To determine if contrast-enhanced electron beam CT (EBCT) can detect areas of acute myocardial ischemia, and if pharmacological stress testing improves the diagnostic accuracy of EBCT. MATERIAL AND METHODS: We injected 0.5 ml/kg and 1.0 ml/kg b.w. of iopromide at a rate of 4 ml/s into the right atrium of 5 ventilated female minipigs at rest and after occlusion of the left anterior descending (LAD) coronary artery. Both ventricles were examined at six short axis levels with an EBCT unit. Myocardial perfusion was calculated from the time-density curves of four left ventricular myocardial segments and the aorta. We also tested the effect of the contrast agent on myocardial density after i.v. administration of 0.6 mg/kg dipyridamole before and after LAD occlusion. RESULTS: At rest, the contrast agent increased myocardial density by 28+/-2 HU, corresponding to a myocardial perfusion estimate of 67+/-7 ml/min/100 g. After dipyridamole, myocardial density increased by 29+/-4 HU. Following occlusion of the LAD, anteroseptal myocardium displayed 10+/-4 HU density increase. The area of non-enhancement corresponded to ischemic myocardium in stained pathologic sections. CONCLUSION: Contrast-enhanced stress EBCT can be used to detect areas of myocardial ischemia, and EBCT stress perfusion imaging may be necessary to consistently differentiate ischemic from non-ischemic myocardial tissue.

[The use of cross-sectional imaging modalities in the diagnosis of heart valve diseases]. / Einsatz moderner Schnittbildverfahren in der Diagnostik von Herzklappenerkrankungen.

Exact visualization of valve morphology seems to be possible with the cross-sectional imaging modalities, magnetic resonance imaging (MRI) and the recently introduced technique of multi-detector computed tomography (MDCT). These techniques are used, if other non-invasive imaging modalities, like echocardiography, fail or provide only insufficient information. This commonly occurs in the assessment of right ventricular valves. Quantification of valve stenosis is possible by calculating valve orifice area, which can be performed with MRI and MDCT. An estimation of the instantaneous peak gradient can only be achieved by MR flow measurements. MR flow measurement is a reliable method to quantify the degree of mild to moderate stenoses. Quantification of valve regurgitation is possible by measurement of the regurgitation fraction with MR flow measurements as well as with MR volumetry/CT volumetry. But only the MR flow measurement is suitable for the quantification of valve regurgitation in patients with multiple valves involved or cardiac shunting. MRI and probably MDCT are the most reliable methods in the evaluation of ventricular volumes and therefore suitable for the follow-up in patients with valvular heart disease, because changes in volumes are important for therapeutic decisions in these patients. The crucial advantages of MRI compared to CT in the diagnostic of valvular heart diseases however are the absence of radiation exposure, the possibility of quantitative evaluation of valves function using flow measurements and the higher temporal resolution as compared to MDCT.

[Multi-slice spiral CT: 3D CT angiography for evaluating therapeutically relevant stenosis in peripheral arterial occlusive disease]. / Mehrschicht-Spiral-CT: 3D CT-Angiographie zur Evaluation therapeutisch relevanter Stenosen bei peripherer arterieller Verschlusskrankheit.

PURPOSE: Evaluation of 3D multislice CT angiography for the assessment of relevant stenoses of pelvic arteries and arteries of the lower extremity in patients with peripheral artery occlusive disease compared to digital subtraction angiography. METHOD/MATERIALS: For this study we examined 31 patients with peripheral artery occlusive disease. All patients received a multislice helical CT angiography and arterial digital subtraction angiography. Multislice CT angiography was performed with a Somatom Plus 4 Volume Zoom (Siemens, Erlangen, Germany). After test bolus injection of 20 ml Ultravist 370 (Schering AG, Berlin) additional 150 ml were applied with a flow rate of 3 ml/sec and a scan delay between 20-35 sec depending on individual blood circulation time. Collimation was 4 x 2.5 mm with a pitch of 6. Reconstructed slice thickness was 3 mm. 3D reconstructions of arteries of pelvic and lower extremity arteries were performed in volume rendering technique on a 3D Virtuoso workstation (Siemens, Erlangen). RESULTS: For the assessment of therapeutically relevant stenoses (over 50% reduction of luminal diameter) multislice CT achieved the following results compared to conventional angiography for the diagnosis of stenosis: sensitivity of 86%, specificity of 86% and an accuracy of 72%. CONCLUSIONS: Multislice helical CT angiography of pelvic arteries and arteries of the thigh represents a reliable means for the detection of relevant stenoses in patients with peripheral occlusive artery disease.

[The use of cross-sectional imaging modalities in the diagnosis of valvular heart disease]. / Einsatz moderner Schnittbildverfahren in der Diagnostik von Herzklappenerkrankungen.

Exact visualization of valve morphology seems to be possible with the cross-sectional imaging modalities, magnetic resonance imaging (MRI) and the recently introduced technique of multidetector computed tomography (MDCT). These techniques are used, if other non-invasive imaging modalities, like echocardiography, fail or provide only insufficient information. This commonly occurs in the assessment of right ventricular valves. Quantification of valve stenosis is possible by calculating valve orifice area, which can be performed with MRI and MDCT. An estimation of the instantaneous peak gradient can only be achieved by MR flow measurements. MR flow measurement is a reliable method to quantify the degree of mild to moderate stenoses. Quantification of valve regurgitation is possible by measurement of the regurgitation fraction with MR flow measurements as well as with MR volumetry/CT volumetry. But only the MR flow measurement is suitable for the quantification of valve regurgitation in patients with multiple valves involved or cardiac shunting. MRI and probably MDCT are the most reliable methods in the evaluation of ventricular volumes and therefore suitable for the follow-up in patients with valvular heart disease, because changes in volumes are important for therapeutic decisions in these patients. The crucial advantages of MRI compared to CT in the diagnostic of valvular heart diseases however are the absence of radiation exposure, the possibility of quantitative evaluation of valves function using flow measurements and the higher temporal resolution as compared to MDCT.