[Magnetic resonance imaging in rheumatology]. / Magnetresonanztomographie in der Rheumatologie.

Imaging plays a major role in the diagnosis and meanwhile also in the therapy control of rheumatic diseases. Besides the commonly used X-ray technique and musculoskeletal ultrasound, magnetic resonance imaging (MRI) is able to provide a three-dimensional view of musculature, ligaments, tendons, capsules, synovial membranes, bones and cartilage with high resolution quality. Therefore, MRI is being employed more and more in the early diagnosis of inflammatory joint and spinal diseases. Contrast-enhanced MRI enables an assessment of disease activity and a differentiation between active and chronic joint manifestation. The technical examinations by MRI are these days standardized and invariably reproducible. This makes it possible to document the course of a disease and allows subsequent treatment decisions. In addition to midfield (>0.5<1.0 T) and high field MRI (>1.0 T), low field MRI (<0.5 T) is used in rheumatology as a patient-friendly office-based technique.

Staging of recurrent and advanced lung cancer with 18F-FDG PET in a coincidence technique (hybrid PET).

The aim of this study was to evaluate [18F]fluorodeoxyglucose ( F-FDG) imaging of recurrent or inoperable lung cancer using a hybrid positron emission tomography (PET) device of the third generation. Examinations were compared with the results of conventional staging. Thirty-six patients suffering from recurrent or primarily inoperable lung cancer (29 men, seven women; age 64.8+/-12.0 years) were examined using hybrid PET (Marconi Axis gamma-PET ) 60 min after injection of 370 MBq F-FDG. The data obtained were reconstructed iteratively. All patients received a computed tomography (CT) scan using either the spiral or multislice technique. All lesions suspicious for primary or recurrent tumour were verified by biopsy; mediastinal lymph nodes were considered as malignant, when positive histology or a small axis diameter of greater than 1 cm measured with CT in addition to progression of clinical course was found. Distant metastases were diagnosed by CT and bone scintigraphy. Using hybrid PET all lesions showed a focally elevated glucose metabolism. Lymph node involvement of the ipsilateral peribronchial and hilar station (N1) was identified in 24/26 cases (92%), in 26/29 cases (90%) of ipsilateral central manifestation (N2) and in 11/13 (85%) cases of central contralateral or supraclavicular lymphatic infestation (N3). Pulmonary spread in hybrid PET was found in 4/8 cases (50%), whereas mainly lung metastases with a diameter of 1.5 cm and smaller were missed. Pleural involvement diagnosed by CT was verified in 4/5 patients. All four patients with bony metastases in conventional staging also presented with positive findings in hybrid PET (8/9 lesions). Concordance with conventional staging was found in 28/36 of patients (78%). In 4/36 patients (11%) unknown sites of tumour were detected leading to therapeutic consequences in three patients after radiological confirmation. Hybrid PET would have led to an understaging in four cases (11%), resulting theoretically in inefficient treatment in two patients. Hybrid PET for F-FDG imaging in the staging of recurrent or primarily inoperable lung cancer supplied equal (78%) or more information (11%) compared to conventional staging procedures. Using the information of hybrid PET alone, 11% of the patients would have been understaged. We conclude that hybrid PET has the potential for use as an additional staging tool in this subgroup of patients, providing supplementary information compared to conventional staging modalities.

Adult moyamoya disease with peripheral artery involvement.

We report the case of a young white woman in whom cerebrovascular moyamoya disease, which was associated with nonarteriosclerotic peripheral artery disease of the subclavian, iliac, and femoropopliteal arteries, was diagnosed by means of angiography. During 8 years of follow-up, the peripheral artery disease progressed, without any signs characteristic of systemic inflammation or vasculitis, leading to severe calf and arm claudication. Despite the absence of histologic confirmation, this observation strongly suggests that peripheral artery involvement may be a feature of moyamoya disease. To our knowledge, this is the first report of an association of classical cerebrovascular moyamoya disease with peripheral artery disease.

[1: Clinical aspects, laboratory diagnosis and therapy. Low backache--when is sacroiliitis the cause?]. / Teil 1: Klinik, Labordiagnostik und Therapie. Kreuzschmerzen--Wann steckt eine Sakroiliitis dahinter?

Despite the availability of modern imaging modalities, early diagnosis of sacroiliitis remains a challenge. The patient's history and the results of the clinical examination form the basis for establishing a working diagnosis, which then needs to be confirmed by laboratory tests and diagnostic imaging. Common causes of sacroiliitis are inflammatory diseases of the spine, in particular seronegative spondyloarthropathies; infectious sacroiliitis is much less common. Besides serological testing (HLA-B27), imaging techniques are essential for diagnosing early forms of sacroiliitis. The treatment of the condition initially involves the use of non-steroidal anti-inflammatory drugs (NSAIDs). In patients with infectious sacroiliitis, antibiotics are the treatment of choice. Local application of steroids, or physiotherapy, can be helpful. The value of disease-modifying drugs (DMARDs) (sulfasalazine, methotrexate) has not been verified, and is questionable. New approaches such as anti-tumor necrosis factor alpha (anti-TNF alpha) need to be tested in controlled studies.

[Roentgen, magnetic resonance with contrast medium, scintigraphy. Staged diagnosis of sacroiliitis]. / Röntgen, Kernspin mit Kontrastmittel, Szintigraphie. Stufendiagnostik der Sakroiliitis.

Radiographic imaging techniques including conventional tomography and computed tomography play a major role in the diagnosis of sacroiliitis (SI). In acute or early stages, however, it may take years before the first morphologic changes become apparent, and the diagnosis of early stages of sacroiliitis still challenges the diagnostician. While scintiscanning is capable of depicting early changes to the joints, it has only low specificity, and interpretation is often difficult, especially in young patients or in cases with bilateral SI arthritis. Contrast-enhanced magnetic resonance imaging (MRI) holds out promise of offering a solution to this problem. With no radiation dose to the patient, MRI is capable of reliably depicting early, acute and chronic alterations to the sacroiliac joints.

[Angina abdominalis: duplex ultrasound diagnosis and percutaneous revascularization]. / Angina abdominalis: duplexsonographische Diagnostik und perkutane Revaskularisierung.

Intestinal ischemia is still a challenge for clinicians and requires a close interdisciplinary cooperation between internist, surgeon and radiologist. In the last years the diagnosis and therapy, classically invasive and surgical, was supplemented by duplex ultrasound and percutaneous techniques like angioplasty and stenting. A 56 year-old man from Greece presented with epigastric pain, which was intensified by food ingestion. These symptoms were caused by a stenosis of the superior mesenteric artery, which was diagnosed by duplex sonography and angiography. No blood flow was detected in the inferior mesenteric and the celiac artery. Occlusion of one internal carotid artery made the patient a poor candidate for surgery. Therefore an interventional approach was chosen. A good result was achieved by angioplasty and stent implantation. On the day after the intervention oral food intake was possible without any pain. 18 months after the intervention the patient was free of abdominal symptoms. Therapy of mesenteric ischemia by percutaneous angioplasty and stenting is published only in case-reports and small series. Therefore the indication is mainly restricted to patients with a high risk for a surgical intervention.

Endoluminal repair of peripheral arterial aneurysms: 4-year experience with the cragg endopro system I.

PURPOSE: To assess the efficiency and long-term patency of the Cragg EndoPro System I in patients with peripheral arterial aneurysms. MATERIALS AND METHODS: In 10 patients, 13 stent-grafts were used to treat 15 arterial aneurysms. Aneurysms were located in the common iliac (n = 4), superficial femoral (n = 4), popliteal (n = 3), and subclavian arteries (n = 2), and in a femoropopliteal bypass-graft (n = 2). Follow-up ranged between 2 and 46 months (mean, 36 months). Examination included clinical status, color-coded duplex sonography, computed tomography angiography, and intra-arterial digital subtraction angiography (DSA). RESULTS: Technical success was achieved in all patients. Primary patency was four of four in iliac vessels and three of nine in non-iliac vessels; secondary patency in noniliac vessels was four of nine. Repairs included one local lysis, four percutaneous transluminal angioplasties, one surgical thrombectomy, and one bypass surgery. Stent wire disintegration was detected in one of four iliac stent-grafts and in seven of nine noniliac stent-grafts. In noniliac grafts, significant stenoses occurred in three of nine; occlusion occurred in five of nine. One complication at the iliac level was a vessel wall penetration at the proximal stent edge, with development of a new aneurysmal formation. No late endoleaks were found. CONCLUSION: Exclusion of peripheral arterial aneurysms with stent-grafts is feasible. Long-term results are excellent in iliac vessels. Mechanical weakness of the stent assembly and frequent re-stenoses or occlusions are significant drawbacks in noniliac vessels with low patency rates.

[Simultaneous vascular and endovascular surgery of complex vascular diseases]. / Simultane vaskuläre und endovaskuläre Chirurgie der komplexen Gefässerkrankungen.

Complex vascular disease requires combined, intraoperative endovascular and reconstructive therapy. Hereby, transprosthetic, transluminal angioplasty is particularly well suited for this purpose. The 5-year patency rate after combined inguinal patch plasty and femoral balloon dilation (n = 58) was 70%. The 5-year patency rates following transgraft angioplasty, with subsequent stent implantation and cross-over bypass (n = 46) and after transprosthetic, popliteal-crural dilation was 83% and 63%, respectively. Three patients with a type IIb (after Allenberg) aneurysm were treated with an aortoiliac stent prosthesis, combined with a cross-over bypass. The follow-up examinations at 2, 16 and 36 months were uneventful.

MR imaging of soft-tissue changes after percutaneous transluminal angioplasty and stent placement.

PURPOSE: To evaluate the different tissue reactions at magnetic resonance (MR) imaging after balloon dilation and placement of covered and uncovered stents. MATERIALS AND METHODS: Contrast material-enhanced MR imaging was performed in 14 patients with polyester-covered nitinol stents, 10 patients with conventional metallic stents, and 12 patients who underwent peripheral percutaneous transluminal angioplasty. Lesions were located in the subclavian, iliac, femoral, and popliteal arteries. RESULTS: MR imaging demonstrated perivascular soft-tissue inflammation in 11 of 14 (79%) patients with polyester-covered stents. Eight (57%) of these patients showed clinical symptoms. No reaction was found among the group with uncovered stents and those who underwent peripheral percutaneous transluminal angioplasty. CONCLUSION: The polyester-covered nitinol stent can induce systemic and severe local reactions. These reactions seem to be specific to this type of stent. No definite cause has been established, although the phenomenon appears to be self-limiting.

Contrast-enhanced MRI of the breast after limited surgery and radiation therapy.

OBJECTIVE: Posttherapeutic changes in the breast after tumorectomy (TE) and radiation therapy (RT) may mimic or obscure recurrent or new malignancies and thus interfere with conventional diagnostic studies. We investigated the enhancement of tissue during variable time intervals after therapy with contrast-enhanced MRI in 62 patients. MATERIALS AND METHODS: We report the results of 77 studies in 62 patients undergoing TE and RT. We include only those studies with at least 24 months of clinical and mammographic follow-up (n = 60) or histopathologic results (n = 17). RESULTS: Up to 9 months after therapy, differentiation between posttherapeutic changes and recurrence was frequently impossible because of the strong enhancement. Ten to 18 months after therapy, this posttherapeutic enhancement subsided slowly with some interindividual variations. After 18 months posttherapy, no significant enhancement was encountered in 30 of 32 cases. Diffuse or focal enhancement was present in all recurrent tumors and all recurrences were correctly diagnosed. Furthermore, 4 of 11 recurrences and 10 of 18 single recurrent foci were detected by MR alone, based on focal enhancement. CONCLUSION: Accordingly, contrast-enhanced MR is not recommended during the first 9 months after therapy. Nine to 18 months after therapy, it may be helpful in those two-thirds of cases where the scar does not enhance. If enhancement takes place (one-third of cases), it may represent either scar or tumor, and in such circumstances, enhanced MR is of no value. After 18 months, enhanced MRI has proven a valuable additional tool. By correctly detecting or excluding recurrent tumor, it can significantly improve diagnostic accuracy.

Rehabilitation of the cancer patient.

Cancer patients often require extensive rehabilitation after treatment. Organization of a rehabilitation team and determination of its goals are a primary aim of such programs. Studies of job security and insurability demonstrate significant problems and biases toward the cancer patient. Discussion has been made of specific male and female sexual rehabilitation programs as well as programs directed at other physical disabilities secondary to head and neck or amputation surgery. Attention is drawn toward familiarizing the surgeon with these problems in order to enhance his treatment of the cancer patient.

Carpal tunnel syndrome in the nonparetic hands of hemiplegics. Stress-induced by ambulatory assistive devices.

Three patients who had earlier sustained an acute stroke were admitted to a rehabilitation bed service. Clinically, they developed symptoms suggestive of carpal tunnel syndrome (CTS) in their nonparetic hands during a progressive ambulation training program which included ambulatory assistive devices. In each patient, the diagnosis was confirmed by electrodiagnostic evaluation. Two of the three patients were subsequently provided with forearm platform attachments for their assistive devices, and cock-up wrist splints, in an attempt to decrease compression of the median nerve. Despite these measures, both remained symptomatic and had electrodiagnostic evidence of progressive CTS. They were referred for surgical decompression of the median nerve. The third patient had resolution of symptoms when she became able to ambulate without need of an assistive device. These cases are examples of CTS secondary to excessive pressure in the nonparetic hands of hemiparetic patients, believed to occur more frequently than is clinically recognized.

Evoked sensory nerve action potentials: effect of different recording electrodes on distal latencies and amplitudes.

The evoked sensory nerve action potentials (ESAP) of the median nerve were studied in 20 subjects using an antidromic technique, recording the distal latency to onset and to peak, and peak to peak amplitude, using three different recording electrodes. The electrodes used were the TECA digital ring electrodes, AERO MED wire loop stretch and squeeze-type electrodes, and Neurodiagnostic finger clip electrodes. Because the Neurodiagnostic finger clip electrodes are wider than the others, they were placed at different points over the proximal and distal interphalangeal joints to evaluate any changes in the ESAP caused by different interelectrode distance. The values obtained for the distal latencies and amplitudes for each electrode were compared using the unpaired Student's t-test. There were no statistically significant differences found in the ESAP distal latencies to onset or peak using any of the electrodes or various placements. When comparing the amplitude responses, the only statistically significant difference was noted when the TECA digital ring electrodes were compared to a particular arrangement of the Neurodiagnostic finger clip electrodes (p less than 0.05). It was therefore concluded that any of these electrodes can be used to obtain reliable reproducible data for nerve conduction studies.