[Endovascular treatment of a thoraco-abdominal aortic aneurysm in case of a specific aortitis]. / Endovaskuläre Therapie eines Aneurysma der thorakoabdominellen Aorta bei einer spezifischen Aortitis.

Successful endovascular repair of an aortic aneurysm of the descending thoracic aorta, laying directly cranial of the celiac artery, caused by a spondylodiscitis of the thoracoabdominal spine. While vascular surgeons refused the open resection of the infected aneurysm, endovascular treatment with a stent-graft was performed. Respecting the celiac artery by catheterisation, endovascular treatment was managed without occluding the A. Adamkiewicz. In case of an unknown infection peri- and postoperative treatment was performed of a prolonged antibiotic and corticosteroid therapy. In a follow-up of three months period, there was a complete regression of the inflammatory aneurysm and an improvement of the spondylodiscitis.

[Management of seriously injured patients without conventional radiography? Does a whole body MSCT scanner replace the conventional X-ray unit in the emergency room?]. / Schockraummanagement ohne konventionelle Radiographie? Macht der Computertomograph die Röntgenröhre überflüssig?

BACKGROUND: [corrected] In the Wuerzburg University level one trauma centre, mobile whole-body multislice computed tomography (MSCT) is used as the primary diagnostic tool in multiple trauma patients. A conventional X-ray unit is not available directly in the resuscitation room of the trauma suite. Three cases are reported to discuss whether state-of-the-art trauma management can be done without conventional radiography. METHODS: In each of the three cases reported here, an emergency situation has occurred in which the emergency diagnosis of the chest with the CT-scan was found to be difficult or impossible. These specific situations are described and discussed for each case and a conclusion is given at the end of this paper. RESULTS: Three scenarios were identified in which conventional radiological diagnostics seemed to be necessary in the emergency room despite the availability of the MSCT. One is the patient undergoing cardiopulmonary resuscitation, the second is the patient that deteriorates after CT-diagnostic is completed and the third is technical problems with the CT-scanner. CONCLUSION: Whole-body MSCT is not sufficient as the sole diagnostic tool in hemodynamically instable trauma patients requiring resuscitation and needs to be complemented by a conventional x-ray unit for emergency diagnosis of the chest.

Accessory joints between basiocciput and atlas/axis in the median plane.

To explore the many osseous irregularities that are found in the area between the basiocciput, the anterior arch of the atlas and the tip of the dens axis we studied 99 cadaver specimens using magnetic resonance tomography (MRT), computed tomography (CT), median saw-cut sections, and histological sections. Additionally, "dry" specimens of the skull (n = 110), atlas (n = 56), and axis (n = 33) were investigated. In the median plane, the dry and cadaver specimens exhibited osteoarthritis-related osseous outgrowths and osteophytes of the articular surfaces of the median atlanto-axial joint (n = 63), and the presence of congenitally developed free ossicles (n = 22) and of third occipital condyles (n = 3). The largest osteophytes (giant osteophytes) (n = 4) of the anterior arch of the atlas formed osseous contact zones with the basiocciput that were visible histologically as real joints and were designated accessory median atlanto-occipital joints. The third occipital condyles also formed osseous contact zones, visible histologically as real joints, with the anterior arch of the atlas or with the tip of the dens, and were designated accessory atlanto-occipital or occipito-odontoid joints. Frequent free ossicles, incorporated into the accessory joint, were found by histological examination to be covered with hyaline cartilage.

[The Würzburg polytrauma algorithm. Concept and first results of a sliding-gantry-based computer tomography diagnostic system]. / Der Würzburger Schockraumalgorithmus. Gesamtkonzept und erste Ergebnisse einer "sliding-gantry-basierten" Computertomographiediagnostik.

BACKGROUND: The purpose of this study was to show the practicability of a new algorithm in the management of polytraumatized patients based on Advanced Trauma Live Support (ATLS) and using mobile whole body multislice CT (MMDCT) as the primary imaging system. PATIENTS AND METHODS: A series of 120 trauma patients referred to the Würzburg University Hospital Trauma Emergency Room were categorized into suspected polytrauma and suspected non-polytrauma groups. The polytraumatized patients were investigated using the Würzburg polytrauma-algorithm including whole body multislice CT with a 16-row-scanner. The algorithm is described. The time for the diagnostic procedure was measured and compared with data from the Trauma Registry of the German Society of Trauma Surgery. RESULTS: From 120 patients 78 (66%) underwent whole body CT. The diagnostic procedure was quick with significant advantages especially for cranial and trunk diagnostics. CONCLUSION: The Würzburg polytrauma algorithm worked well. There was excellent cooperation within the interdisciplinary leading team consisting of anaesthesiologists, surgeons, and radiologists. The principles of ATLS could be respected. Mobile whole body multislice CT was an effective tool in the diagnostic evaluation of polytrauma patients.

[Percutaneous transhepatic retrieval of an intraoperatively displaced biliary stent]. / Perkutane transhepatische Entfernung eines intraoperativ belassenen Gallengangsstents.

Biliary stents play an important role in the treatment of jaundice due to malignant and/or benign diseases of the bile duct. Biliary stents are primarily introduced endoscopically whereas the percutaneous transhepatic technique is employed after endoscopic failure. Proximal and distal displacement or migration is a rare complication, but there is a risk of considerable morbidity and mortality, so that the extraction of the prosthesis is recommended in these cases. Again, endoscopic removal is the approach of choice. For stent retrieval multiple techniques have been described, including Dormia basket, special forceps, Fogarty balloon catheter, ball tip catheter and loop catheter. Endoscopic recovery often uses a combination of these techniques reaching a success rate of 90%. However, in patients following hepaticojejunostomy or Bilroth II procedure an endoscopic retrieval cannot be performed for obvious technical reasons. Consequently, percutaneous transhepatic stent removal must be considered. Ensuring a correct technique transhepatic removal is equally successful and safe, thus eliminating the risks of a surgical procedure.

[Pseudoaneurysm of the right gastric artery]. / Pseudoaneurysma der A. gastrica dextra.

Mostly, the rare pseudoaneurysm of the right gastric artery is a complication of a pancreatitis. Clinical findings might be normal, but there is also a hemorrhagic shock in case of rupture. Diagnostic procedures are ultrasound, colour doppler ultrasound, computertomography and angiography for treatment. While endoscopy does not enable a therapeutic approach, interventional radiology with transcatheter embolization is a modality, which can be performed fast, sure and without complications. In case of an intractable acute hemorrhage the embolization is an alternative to surgical emergency.

The third occipital condyle, a constituent part of a median occipito-atlanto-odontoid joint: a case report.

A compound conjunction between basiocciput, atlas (anterior arch), and dens of axis (odontoid process) was found incidentally during routine dissection of the head of an 83-year-old man. According to the patient's history, no neck disability had been recorded. A median saw-cut of the head-and-neck conjunction revealed that the basion was anteriorly reinforced by an osseous pillar 4 mm in length and 3 mm in width. Such a formation is known as a third occipital condyle (condylus tertius, CT). In our case it exhibited one surface oriented in an anterior-inferior direction and articulating with the superior border of the anterior arch of the atlas, and another surface oriented in a posterior-inferior direction and articulating with the superior portion of the dens of axis. The dens of axis itself articulated with the anterior arch of the atlas, forming the (normal) median atlanto-axial joint. Post-mortem computed tomography and post-mortem histological examination completed the investigation. The cartilage of the articular compartment between the CT and the anterior arch of the atlas and the related anterior fibrous disc exhibited severe arthrosis. The findings were discussed in the light of developmental and comparative anatomy.

[Evaluation of ventral stabilization techniques for thoracolumbar fractures by helical computer tomography]. / Beurteilung der ventralen Stabilisierungstechniken thorakolumbaler Wirbelsäulenverletzungen mit Hilfe der Computertomographie.

PURPOSE: To assess the volumetric change of the implanted graft in thoracolumbar fractures treated with dorsal and ventral stabilization. Comparison of two methods of ventral stabilization to avoid loss of correction and rekyphosis. MATERIAL AND METHODS: 38 patients with 40 thoracolumbar fractures were treated with a tricortical bone graft of the pelvis (n = 27) or bone cement (SRS: skeletal repair system, n = 13), measuring the volume and the length of the implanted graft by helical CT (Somatom Plus 4, Siemens): after ventral stabilization, preoperative before and six month after removal of the fixateur interne. The bone and SRS volume were assessed as a product of slice thickness and cross-section, the length of the implanted graft was measured by the cranial and caudal table position. RESULTS: Loss of graft volume between implantation and explantation of the fixateur interne was 24.3 %, and between implantation and the check six months after removal 40.5 %; loss of length until removal 14.6 % and between implantation and six months after the removal 24.1 %; no difference between the tricortical bone graft and the skeletal repair system. CONCLUSION: Volumetric and length study assessed by CT shows a loss of volume and length of the tricortical bone graft and the skeletal repair system with no dependence on the used material. CT enables an exact and feasible assessment of the localisation, volume, size and possible complications of the implanted bone graft and SRS. The considerable loss of volume and length of the graft is one of the reasons correction loss and rekyphosis in the stabilization of the thoracolumbar fractures.

[Which imaging in case of sigmoid diverticulitis? The value of ultrasound (Conventional B-mode in combination with hydrocolonsonography and colour flow Doppler) in comparison to the well-established modalities like contrast enema and helical computertomography]. / Welche bildgebende Diagnostik bei Verdacht auf eine Sigmadivertikulitis? - Wertigkeit der sonographischen Untersuchungsverfahren (konventionelle B-Bild-Diagnostik in Kombination mit der Hydrokolonsonographie und der farbkodierten Duplexsonographie) im Vergleich mit den etablierten Verfahren wie dem Kolon-Kontrasteinlauf und der Spiral-Computertomographie -

Sigmoid diverticulitis is in case of complications like perforation, abscess and peritonitis a life-threatening disease. A diagnostic work up with high sensitivity is mandatory. In a prospective study upon 247 patients with the possible diagnosis of acute diverticulitis ultrasound is a screening method with a high specificity (97 %) and leads in combination with the hydrocolonsonography and the colour flow doppler to a high sensitivity (76 %). Without any typical findings in ultrasound, helical CT scan is the best method in the evaluation of the acute diverticulitis (sensitivity and specificity 100 %), because contrast enema is inferior to CT in the evaluation of abscesses (6 %) and perforation (53 %). CT has in case of perforation and of abscesses a sensitivity of 90 % and 100 %, while ultrasound has a sensitivity of 12 % to perforation and of 39 % to abscesses.

Abdominal actinomycosis: complication of endoscopic stenting in chronic pancreatitis?

Pancreatic endotherapy is frequently performed in patients with chronic pancreatitis and stenoses of the main pancreatic duct. In a patient with long-standing chronic pancreatitis and treatment with pancreatic stents, metastatic pancreatic head carcinoma was suspected because of infiltration of the neighboring organs and hepatic lesions. Ultrasound-guided aspiration of one liver lesion revealed grains typical for actinomycosis. In the light of this case, an extracted pancreatic stent was microbiologically investigated for actinomycetes in another patient who had a suspicious lesion of the pancreatic head. Microbiological examination of the extracted pancreatic stent revealed colonization by Actinomyces meyeri, Klebsiella oxytoca, and mixed cultures of anaerobic and saprophytic Gram-positive bacteria. In the following weeks, she developed a septic clinical picture with multiple abscesses of the liver. Actinomyces meyeri, Corynebacterium species, Candida and Enterococcae were cultivated in the aspirates. It seems possible, that treatment with pancreatic stents could have caused invasion of actinomycetes into the parenchyma of the pancreas, which was already harmed by the chronic inflammation, followed by the typical infiltrative growth and hematologic or biliary seeding into the liver.

[Embolization of aneurysma spurium of the superior gluteal artery]. / Embolisationsbehandlung eines Aneurysma spurium der A. glutea superior.

While for the surgical treatment there are the transgluteal and the retroperitoneal approach, the alternative radiological modality is less invasive. It is performed by a from contralateral placed guidant-catheter in combination with a tracker catheter with the possibility of transcatheter embolization with liquid, particles or coils. The rate of success is high, complications are seldom and the hospital stay is short. Both modalities can and should be used complementary. In the case of an intractable acute hemorrhage transcatheter embolization should be used firstly.

Follicular or dentigerous (tooth-containing) cyst in the premaxilla of an otherwise edentulous 65-year-old man.

A unilocular follicular or dentigerous cyst (FDC) with a diameter of 12 mm was observed incidentally in the premaxilla of a midsagittal section of the head of a 65-year-old cadaver. The mucosal lining of the cyst was grey in color and granular in texture: the osseous walls had a thickness of less than 1 mm. In the floor of the cyst, a slender, fully developed incisor tooth was fixed in a horizontal position. The alveolar processes of the maxilla and mandible were completely edentulous. Postmortem computer tomography showed the cyst in an osteolytic lesion of the premaxilla, and histology revealed a lining of non-keratinized stratified squamous epithelium supported by a lamina propria of dense connective tissue.

Medium-term functional benefits in children with cerebral palsy treated with botulinum toxin type A: 1-year follow-up using gross motor function measure.

One of the main goals when treating spasticity is to relieve pain and improve function. Intramuscular injection of botulinum toxin type A (BTX-A) has gained widespread acceptance in the treatment of spastic cerebral palsy. Several studies have clearly shown the short-term functional benefit of BTX-A treatment. Information is limited, however, on the efficacy of medium and long-term regimens, using repeated injection of BTX-A. The aim of the present open-label, prospective study was to evaluate functional outcome in children with spastic cerebral palsy after 1 year of treatment with BTX-A, using the Gross Motor Function Measure (GMFM) as a validated outcome measure. Patients (n=25, age 1.5--15.5 years) were treated with BTX-A for adductor spasm (n=12) or pes equinus (n=13). The local effect was evaluated using passive range of motion and modified Ashworth Scale. Apart from a significant improvement in joint mobility and reduction of spasticity compared to pretreatment values (P < 0.01), we demonstrated a significant improvement of gross motor function after 12 months of treatment, with a median gain of 6% in total and goal scores (P < 0.001). An increase in GMFM scores was particularly evident in younger and moderately impaired children (Gross Motor Function Classification System level III). Whether the observed improvement in gross motor function in children with cerebral palsy is specifically related to therapy with BTX-A or represents at least in part the natural course of motor development still needs clarification.

Bioavailability and pharmacokinetics of natural volatile terpenes in animals and humans.

Herbal medicinal products containing natural volatiles are used in the treatment of gastrointestinal diseases, pain, colds and bronchitis. Many pharmacological studies report a wide variety of in vitro effects, with anti-inflammatory and antimicrobial activities investigated most frequently. In comparison, relatively few studies on the bioavailability and pharmacokinetics have been carried out. Thus, the relevance of the in vitro activity to the therapeutic effects found in individual studies or documented in textbooks of phytotherapy is still not established. Further studies with essential oils and their single compounds providing supporting evidence of efficacy and demonstrating systemic availability are necessary. Such data could also be important in the context of safety.

Sonography for selecting candidates for laparoscopic cholecystectomy: a prospective study.

OBJECTIVE: We assessed the value of sonography in predicting intraoperative difficulties for patients undergoing laparoscopic cholecystectomy and in identifying indicators for conversion to conventional cholecystectomy. SUBJECTS AND METHODS: Upper abdominal sonography was performed (according to a checklist) in 75 consecutive patients before laparoscopic cholecystectomy. Sonographic findings were verified by the surgeon in the operating room. RESULTS: Conversion from laparoscopic surgery to laparotomy was performed in five patients (6.7%). Of 75 patients, 19 had sonograms revealing gallbladder wall thickening (>4 mm); surgical preparation difficulties in 16 of these patients led to laparotomy in four patients. Sensitivity, specificity, positive predictive value, and accuracy of wall thickening as an indicator of technical difficulties were 66.7%, 94.1%, 84.2%, and 85.3%, respectively. Sensitivity, specificity, positive predictive value, and accuracy of wall thickening as an indicator of surgical conversion were 80.0%, 78.6%, 21.1%, and 78.7%, respectively. Technical difficulties at laparoscopy occurred in all five patients with pericholecystic fluid on sonography (sensitivity, 20.8%; specificity, 100%; positive predictive value, 100%; accuracy, 74.7%) and led to laparotomy in three patients (sensitivity 60.0%, specificity 97.1%, positive predictive value 60%, accuracy 94.7%). The accuracy of sonography for cholecystolithiasis was 100%. CONCLUSION: On sonography, gallbladder wall thickening is the most sensitive indicator and pericholecystic fluid is the most specific indicator of technical difficulties during laparoscopic cholecystectomy. Such difficulties may require conversion to laparotomy.

[Not Available]. / Bildgebende Verfahren zur Beurteilung der Karotisbifurkation vor und nach Operation bzw. Intervention Stellenwert der farbkodierten Duplexsonographie, der CT-Arteriographie und der digitalen Subtraktionsangiographie : Stellenwert der farbkodierten Duplexsonographie, der CT-Arteriographie und der digitalen Subtraktionsangiographie.

Clinical findings and the correct assessment of the morphology and degree of stenosis is a decidant point in the conservative and operative therapy of carotid stenosis. Diagnosis should be reached fast, sure and cost-effective with a high sensitivity and specifity.One hundred and fifty-nine patients with cerebrovascular disease underwent digital subtraction angiography (DSA), color flow Doppler (CFD) and CT angiography (CTA).We detected 213 severe (> 80%) stenoses (ICA: 151, ECA: 45, CCA: 17), and 32 occlusions (ICA: 27, ECA: 3, CCA: 2). The 3 methods showed all occlusions (sensitivity: 100%). D SA failed in 7 stenosis (sensitivity 96.7%), CTA in 3 cases (98.6%), CFD in 19 stenoses (sensitivity: 92.2%).Morphology of plaques were detected by CTA, which was superior to CFD or DSA. Ulcerations were demonstrated more exactly by CFD and DSA; CTA needs the reformation. Most questions can be answered by CFD, special information should be got by CTA and DSA.

Opacification of the urinary tract in portal venous spiral CT without delayed scans.

In portal venous spiral CT there is no visible renal contrast excretion within the usual period of scanning. To opacify collecting systems additional delayed scanning is required. We administered an extra pre-dose of contrast medium before the main portal venous bolus in order to opacify the urinary tract and studied its effects on liver attenuation. In 32 patients examined first by non-contrast spiral CT 20 ml of a non-ionic IV CM were injected. Five minutes later, orientating cuts in the liver and along the urinary tract were obtained. Immediately thereafter, a 120-ml bolus was administered at 3 ml/s for portal venous phase helical CT (60-s delay craniocaudad). The quality of renal excretion was graded visually (excellent, fair, poor, none). Hepatic attenuation measurements were performed at comparable regions of interest. In all patients 20 ml CM opacified the renal pelvis after 5 min. Depiction of the ureters was excellent in 14, fair in 11 and poor or none in 7 cases. There was little effect on mean hepatic attenuation by the 20-ml pre-bolus after 5 min: mean enhancement 2.3 HU (range -0.6 to 7.8 HU). Mean hepatic enhancement after the 120-ml portal venous bolus ranged between 23.6 and 74.1 HU (mean 51.5 HU). When opacification of the urinary tract is necessary, pre-administration of a 20-ml bolus 5 min before portal venous scanning may save an extra delayed spiral. The effects on hepatic enhancement are negligible.

Helical CT cholangiography for the detection and localization of bile duct leakage.

OBJECTIVE: We describe the use of helical CT cholangiography or helical CT after administration of biliary i.v. contrast material to verify and localize bile duct leakage. CONCLUSION: Helical CT cholangiography revealed bile leaks in seven patients after penetrating trauma or liver or gallbladder surgery and excluded bile leaks in two patients with blunt liver trauma. Endoscopic retrograde cholangiography was performed in only one of seven patients with bile leakage and was avoided in an additional two patients in whom CT cholangiography excluded leakage. The method is a feasible, noninvasive tool for the detection and localization of bile leaks and may help avoid endoscopic retrograde cholangiography.