CT findings in "Post-Covid": residua from acute pneumonia or "Post-Covid-ILD"?

The aim of this study was to evaluate if CT findings in patients with pulmonary Post Covid syndrome represent residua after acute pneumonia or if SARS-CoV 2 induces a true ILD. Consecutive patients with status post acute Covid-19 pneumonia and persisting pulmonary symptoms were enrolled. Inclusion criteria were availability of at least one chest CT performed in the acute phase and at least one chest CT performed at least 80 days after symptom onset. In both acute and chronic phase CTs 14 CT features as well as distribution and extent of opacifications were independently determined by two chest radiologists. Evolution of every single CT lesion over time was registered intraindividually for every patient. Moreover, lung abnormalities were automatically segmented using a pre-trained nnU-Net model and volume as well as density of parenchymal lesions were plotted over the entire course of disease including all available CTs. 29 patients (median age 59 years, IQR 8, 22 men) were enrolled. Follow-up period was 80-242 days (mean 134). 152/157 (97 %) lesions in the chronic phase CTs represented residua of lung pathology in the acute phase. Subjective and objective evaluation of serial CTs showed that CT abnormalities were stable in location and continuously decreasing in extent and density. The results of our study support the hypothesis that CT abnormalities in the chronic phase after Covid-19 pneumonia represent residua in terms of prolonged healing of acute infection. We did not find any evidence for a Post Covid ILD.

Occurrence of spontaneous fistulas detected by contrast filling during computed tomography-guided percutaneous drainage placement of splenic and perisplenic fluid collections.

BACKGROUND: Fistulas are serious complications of splenic and perisplenic fluid accumulations, which are often difficult to detect by routine imaging methods. PURPOSE: To evaluate the occurrence of spontaneous fistulas detectable during computed tomography-guided percutaneous drainage placement (CTGDP) with contrast filling of splenic or perisplenic fluid collections and to assess characteristics in comparison with perihepatic or peripancreatic fluid accumulations, also being treated with CTGDP. MATERIAL AND METHODS: In 127 CTGDP-procedures, pre-interventional CTs conducted with intravenous contrast agent were compared to post-interventional CTs including contrast filling of the drain to identify spontaneous fistulas. Patient and case characteristics were evaluated, and therapeutic consequences of fistula identification were analyzed. RESULTS: A total of 43 perisplenic, 40 peripancreatic, and 44 perihepatic drains were evaluated; 13 (30.2%) perisplenic, 7 (17.5%) peripancreatic, and 10 (22.7%) perihepatic fistulas were observed. Concerning the frequency of fistulas, no significant difference was found between the patient groups (P = 0.39). All fistulas were solely proven in CT scans including contrast filling of the drain. Seven fistulas (23.3%) required additional interventions. Perihepatic drains were significantly more often associated with recent surgery (P < 0.001). The mean size of peripancreatic drains was significantly greater (11.8 ± 3.9 F; P < 0.001) than in perihepatic or perisplenic fluid collections. CONCLUSION: Spontaneous fistulas detected during CTGDP of splenic or perisplenic fluid collections are common. Post-interventional contrast filling of the drain drastically improves the detection rate of perisplenic, peripancreatic and perihepatic fistulas simultaneously initiating appropriate follow-up interventions.

Assessment of Association Between Venous Occlusion and Infection of Cardiac Implantable Electronic Devices.

The increasing number of patients treated with cardiac implantable electronic devices (CIEDs) and indications for complex pacing requires system revisions. Currently, data on venous patency in repeat CIED surgery involving lead (re)placement or extraction are largely missing. This study aimed to assess venous patency and risk factors in patients referred for repeat CIED lead surgery, emphasizing CIED infection. All consecutive patients requiring extraction, exchange, or additional placement of ≥1 CIED leads during reoperative procedures from January 2015 to March 2020 were evaluated in this retrospective study. Venography was performed in 475 patients. Venous patency could be assessed in 387 patients (81.5%). CIED infection with venous occlusion was detected in 74 patients compared with venous occlusion without infection in 14 patients (P < .05). Concerning venous patency, novel oral anticoagulant medication appeared to be protective (P < .05; odds ratio [OR]: .35). Infection of the CIED appeared to be strongly associated with venous occlusion (OR: 16.0). The sensitivity was only 64.15%, but the specificity was 96.1%. Number of leads involved and previous CIED procedures were not associated with venous occlusion. In conclusion, in patients with CIED, venous occlusion was strongly associated with device infection, but not with the number of leads or previous CIED procedures.

Complementary imaging of ultrasound and PET/CT: A new opportunity?

AIM: To evaluate the effectiveness of complementary imaging of high-resolution ultrasound including CEUS with PET/CT for tissue characterization and tumor detection. MATERIAL AND METHODS: 100 patients were examined with PET/CT and US/CEUS between January 2018 until February 2020. All patients underwent PET/CT followed by selective US/CEUS within 4 weeks. Comparison regarding concordant or diverging findings in PET/CT and US. Analysis of the differences concerning the lesions number of found by PET/CT and US/CEUS or the possibility of a secured diagnosis following ultrasound causing therapeutic changes. RESULTS: Diverging findings regarding the number of liver lesions in PET/CT and CEUS were found in 35 out of 64 patients (54%). Regarding renal lesions, a more definite diagnosis following ultrasound, causing a change of therapeutic approach, was achieved in 89%. Concordant results in PET/CT and US were found in 83% of patients with splenic and nodal findings. In 78% of patients with increased musculoskeletal or soft tissue tracer uptake, US was able to make a secured diagnosis with therapeutic changes. CONCLUSION: The present results indicate a strong benefit of complementary imaging of PET/CT and selective, high-resolution ultrasound especially in patients with liver, renal and musculoskeletal or soft tissue findings.

Suspicious breast lesions incidentally detected on chest computer tomography with histopathological correlation.

OBJECTIVE: To evaluate incidental breast lesions on chest computed tomography with histopathological correlation. It is important for general radiologist to characterize a breast lesion as benign, indetermined, or sufficiently suspicious to warrant further work-up. METHODS: A total of 35.000 chest CT examinations were performed between January 2016 and December 2020. 27 patients (mean age 70 years, age range 48-87 years) with incidental breast lesions were identified in this retrospective study. Two radiologists scored incidental breast lesions independently regarding their morphology, and the results were compared to histopathology which was obtained by an ultrasound-guided core needle biopsy or a surgical excision. RESULTS: Out of 35.000 chest CT examinations, a total of 31 incidental breast lesions in 27 patients were detected. Among the 31 lesions, 23 were malignant and 8 benign. The malignant lesions included 17 carcinomas and 6 metastases (4 lymphomas and 2 melanomas). The benign lesions contained 2 hematomas, 4 fat necrosis, and 2 fibrosis lumps. CONCLUSION: Chest computed tomography as a standard imaging technique is helpful for evaluation of suspicious breast lesions. This may ultimately influence patient management and lead to further imaging.

Severe COVID-19 pneumonia: Perfusion analysis in correlation with pulmonary embolism and vessel enlargement using dual-energy CT data.

BACKGROUND: Gas exchange in COVID-19 pneumonia is impaired and vessel obstruction has been suspected to cause ventilation-perfusion mismatch. Dual-energy CT (DECT) can depict pulmonary perfusion by regional assessment of iodine uptake. OBJECTIVE: The purpose of this study was the analysis of pulmonary perfusion using dual-energy CT in a cohort of 27 consecutive patients with severe COVID-19 pneumonia. METHOD: We retrospectively analyzed pulmonary perfusion with DECT in 27 consecutive patients (mean age 57 years, range 21-73; 19 men and 8 women) with severe COVID-19 pneumonia. Iodine uptake (IU) in regions-of-interest placed into normally aerated lung, ground-glass opacifications (GGO) and consolidations was measured using a dedicated postprocessing software. Vessel enlargement (VE) within opacifications and presence of pulmonary embolism (PE) was assessed by subjective analysis. Linear mixed models were used for statistical analyses. RESULTS: Compared to normally aerated lung 106/151 (70.2%) opacifications without upstream PE demonstrated an increased IU, 9/151 (6.0%) an equal IU and 36/151 (23.8%) a decreased IU. The estimated mean iodine uptake (EMIU) in opacifications without upstream PE (GGO 1.77 mg/mL; 95%-CI: 1.52-2.02; p = 0.011, consolidations 1.82 mg/mL; 95%-CI: 1.56-2.08, p = 0.006) was significantly higher compared to normal lung (1.22 mg/mL; 95%-CI: 0.95-1.49). In case of upstream PE, EMIU of opacifications (combined GGO and consolidations) was significantly decreased compared to normal lung (0.52 mg/mL; 95%-CI: -0.07-1.12; p = 0.043). The presence of VE in opacifications correlated significantly with iodine uptake (p<0.001). CONCLUSIONS: DECT revealed the opacifications in a subset of patients with severe COVID-19 pneumonia to be perfused non-uniformly with some being hypo- and others being hyperperfused. Mean iodine uptake in opacifications (both ground-glass and consolidation) was higher compared to normally aerated lung except for areas with upstream pulmonary embolism. Vessel enlargement correlated with iodine uptake: In summary, in a cohort of 27 consecutive patients with severe COVID-19 pneumonia, dual-energy CT demonstrated a wide range of iodine uptake in pulmonary ground-glass opacifications and consolidations as a surrogate marker for hypo- and hyperperfusion compared to normally aerated lung. Applying DECT to determine which pathophysiology is predominant might help to tailor therapy to the individual patient´s needs.

CT Features of COVID-19 Pneumonia Differ Depending on the Severity and Duration of Disease.

BACKGROUND: CT is important in the care of patients with COVID-19 pneumonia. However, CT morphology can change significantly over the course of the disease. To evaluate the CT morphology of RT-PCR-proven COVID-19 pneumonia in a German cohort with special emphasis on identification of potential differences of CT features depending on duration and severity of disease. METHOD: All patients with RT-PCR-proven COVID-19 pneumonia and chest CT performed between March 1 and April 15, 2020 were retrospectively identified. The CT scans were evaluated regarding the presence of different CT features (e. g. ground glass opacity, consolidation, crazy paving, vessel enlargement, shape, and margin of opacifications), distribution of lesions in the lung and extent of parenchymal involvement. For subgroup analyses the patients were divided according to the percentage of parenchymal opacification (0-33 %, 34-66 %, 67-100 %) and according to time interval between symptom onset and CT date (0-5 d, 6-10 d, 11-15 d, > 15 d). Differences in CT features and distribution between subgroups were tested using the Mantel-Haenszel Chi Squared for trend. RESULTS: The frequency of CT features (ground glass opacity, consolidation, crazy paving, bronchial dilatation, vessel enlargement, lymphadenopathy, pleural effusion) as well as pattern of parenchymal involvement differed significantly depending on the duration of disease and extent of parenchymal involvement. The early phase of disease was characterized by GGO and to a lesser extent consolidation. The opacifications tended to be round and to some extent with sharp margins and a geographic configuration. The vessels within/around the opacifications were frequently dilated. Later on, the frequency of consolidation and especially crazy paving increased, and the round/geographic shape faded. After day 15, bronchial dilatation occurred, and lymphadenopathy and pleural effusion were seen more frequently than before. CONCLUSION: The prevalence of CT features varied considerably during the course of disease and depending on the severity of parenchymal involvement. Radiologists should take into account the time interval between symptom onset and date of CT and the severity of disease when discussing the likelihood of COVID-19 pneumonia based on CT morphology. KEY POINTS: · The frequency of CT features and pattern of parenchymal involvement vary depending on the duration and extent of COVID-19 pneumonia.. · The early phase is characterized by GGO and consolidation which demonstrate a round shape and at least to some extent have sharp margins and a geographic configuration.. · The frequency of consolidation and especially crazy paving increases during the course of disease.. · Beyond day 15 after symptom onset, bronchial dilatation occurs.. · Radiologists should take into account the duration and severity of disease when considering COVID-19 pneumonia.. CITATION FORMAT: · Schaible J, Meiler S, Poschenrieder F et al. CT Features of COVID-19 Pneumonia Differ Depending on the Severity and Duration of Disease. Fortschr Röntgenstr 2021; 193: 672 - 682.

Routine restaging after primary non-surgical treatment of laryngeal squamous cell carcinoma-a review.

PURPOSE: Treatment of patients with laryngeal squamous cell carcinoma with radiotherapy or chemoradiation is an established alternative to laryngeal surgery in many cases, but particularly for advanced tumors without cartilage invasion. Imaging modalities face the challenge of distinguishing between posttherapeutic changes and residual disease in the complex anatomic subsite of the larynx. Guidelines concerning restaging of head and neck squamous cell carcinomas (HNSCC) are presented by the National Comprehensive Cancer Network (NCCN) and other national guidelines, but clearly defined recommendations for routine restaging particularly for laryngeal cancer are lacking. METHODS: A systematic search was carried out in PubMed to identify studies evaluating routine restaging methods after primary non-surgical treatment of laryngeal squamous cell carcinoma from 2009 to 2020. RESULTS: Only three studies were deemed eligible, as they included at least ≥50% patients with laryngeal squamous cell carcinoma and evaluated imaging modalities to detect residual cancer. The small number of studies in our review suggest restaging with fluoro-deoxy-glucose positron-emission tomography/computed tomography (FDG PET/CT) 3 months after initial treatment, followed by direct laryngoscopy with biopsy of the lesions identified by FDG PET/CT. CONCLUSION: Studies evaluating restaging methods after organ-preserving non-surgical treatment of laryngeal carcinoma are limited. As radiotherapy (RT), chemoradiotherapy (CRT), systemic therapy followed by RT and radioimmunotherapy are established alternatives to surgical treatment, particularly in advanced laryngeal cancers, further studies are needed to assess and compare different imaging modalities (e.g. PET/CT, MRI, CT, ultrasound) and clinical diagnostic tools (e.g., video laryngoscopy, direct laryngoscopy) to offer patients safe and efficient restaging strategies. PET or PET/CT 3 months after initial treatment followed by direct laryngoscopy with biopsy of the identified lesions has the potential to reduce the number of unnecessary laryngoscopies.

Sharp margin and geographic shape: systematic evaluation of two novel CT features in COVID-19 pneumonia.

OBJECTIVE: CT is important in the care of patients with COVID-19 pneumonia. However, specificity might be poor in the absence of a clinical and epidemiological context. The goal of this work was to systematically evaluate two novel CT features (sharp margin and geographic shape) of COVID-19 pneumonia. METHODS: All patients with reverse transcription polymerase chain reaction proven COVID-19 pneumonia and chest CT between March first and April 15, 2020 were retrospectively identified from two tertiary care hospitals in Germany. The CTs were evaluated regarding the presence of typical CT signs (e.g. ground glass opacitiy, consolidation, crazy paving). Moreover, the shape of the opacifications (round, geographic, curvilinear) and their margin (unsharp, sharp) was determined. RESULTS: The study population comprised 108 patients (64 male) with a mean age of 59.6 years. Ground glass opacities (96%) and consolidation (75%) were the most prevalent CT signs. Crazy paving was seen in 17%, bronchial dilatation in 21%, air bronchogram in 29%, vessel enlargement in 47%, cavitation in 0%, lymphadenopathy in 32%, pleural effusion in 16%. Round configuration of densities was present in 41% of CTs, geographic shape in 27% and curvilinear opacities in 44%. 79% of opacifications were at least partially sharply marginated. In almost all cases, the lung was affected bilaterally (94%). CONCLUSION: The CT pattern of COVID-19 pneumonia in a cohort from Germany was in accordance with prior studies. However, we identified two novel CT signs of COVID-19 pneumonia which have so far not been systematically evaluated. A sharp border and geographic shape of opacifications were frequently observed. ADVANCES IN KNOWLEDGE: The newly described CT features "sharp margin" and "geographic shape" of opacifications in patients with COVID-19 pneumonia might help to increase specificity of CT.

Computed tomography characterization and outcome evaluation of COVID-19 pneumonia complicated by venous thromboembolism.

BACKGROUND: COVID-19 is frequently complicated by venous thromboembolism (VTE). Computed tomography (CT) of the chest-primarily usually conducted as low-dose, non-contrast enhanced CT-plays an important role in the diagnosis and follow-up of COVID-19 pneumonia. Performed as contrast-enhanced CT pulmonary angiography, it can reliably detect or rule-out pulmonary embolism (PE). Several imaging characteristics of COVID-19 pneumonia have been described for chest CT, but no study evaluated CT findings in the context of VTE/PE. PURPOSE: In our retrospective study, we analyzed clinical, laboratory and CT imaging characteristics of 50 consecutive patients with RT-PCR proven COVID-19 pneumonia who underwent contrast-enhanced chest CT at two tertiary care medical centers. MATERIAL AND METHODS: All patients with RT-PCR proven COVID-19 pneumonia and contrast-enhanced chest CT performed at two tertiary care hospitals between March 1st and April 20th 2020 were retrospectively identified. Patient characteristics (age, gender, comorbidities), symptoms, date of symptom onset, RT-PCR results, imaging results of CT and leg ultrasound, laboratory findings (C-reactive protein, differential blood count, troponine, N-terminal pro-B-type natriuretic peptide (NT-proBNP), fibrinogen, interleukin-6, D-dimer, lactate dehydrogenase (LDH), creatine kinase (CK), creatine kinase muscle-brain (CKmb) and lactate,) and patient outcome (positive: discharge or treatment on normal ward; negative: treatment on intensive care unit (ICU), need for mechanical ventilation, extracorporeal membrane oxygenation (ECMO), or death) were analyzed. Follow-up was performed until May 10th. Patients were assigned to two groups according to two endpoints: venous thromboembolism (VTE) or no VTE. For statistical analysis, univariate logistic regression models were calculated. RESULTS: This study includes 50 patients. In 14 out of 50 patients (28%), pulmonary embolism was detected at contrast-enhanced chest CT. The majority of PE was detected on CTs performed on day 11-20 after symptom onset. Two patients (14%) with PE simultaneously had evidence of deep vein thrombosis. 15 patients (30%) had a negative outcome (need for intensive care, mechanical ventilation, extracorporeal membrane oxygenation, or death), and 35 patients (70%) had a positive outcome (transfer to regular ward, or discharge). Patients suffering VTE had a statistically significant higher risk of an unfavorable outcome (p = 0.028). In univariate analysis, two imaging characteristics on chest CT were associated with VTE: crazy paving pattern (p = 0.024) and air bronchogram (n = 0.021). Also, elevated levels of NT-pro BNP (p = 0.043), CK (p = 0.023) and D-dimers (p = 0.035) were significantly correlated with VTE. CONCLUSION: COVID-19 pneumonia is frequently complicated by pulmonary embolism (incidence of 28% in our cohort), remarkably with lacking evidence of deep vein thrombosis in nearly all thus affected patients of our cohort. As patients suffering VTE had an adverse outcome, we call for a high level of alertness for PE and advocate a lower threshold for contrast-enhanced CT in COVID-19 pneumonia. According to our observations, this might be particularly justified in the second week of disease and if a crazy paving pattern and / or air bronchogram is present on previous non-enhanced CT.

Can CT performed in the early disease phase predict outcome of patients with COVID 19 pneumonia? Analysis of a cohort of 64 patients from Germany.

PURPOSE: The aim of this study was to investigate if CT performed in the early disease phase can predict the course of COVID-19 pneumonia in a German cohort. METHOD: All patients with RT-PCR proven COVID-19 pneumonia and chest CT performed within 10 days of symptom onset between March 1st and April 15th 2020 were retrospectively identified from two tertiary care hospitals. 12 CT features, their distribution in the lung and the global extent of opacifications were evaluated. For analysis of prognosis two compound outcomes were defined: positive outcome was defined as either discharge or regular ward care; negative outcome was defined as need for mechanical ventilation, treatment on intensive care unit, extracorporeal membrane oxygenation or death. Follow-up was performed until June 19th. For statistical analysis uni- und multivariable logistic regression models were calculated. RESULTS: 64 patients were included in the study. By univariable analysis the following parameters predicted a negative outcome: consolidation (p = 0.034), crazy paving (p = 0.004), geographic shape of opacification (p = 0.022), dilatation of bronchi (p = 0.002), air bronchogram (p = 0.013), vessel enlargement (p = 0.014), pleural effusion (p = 0.05), bilateral disease (p = 0.004), involvement of the upper lobes (p = 0.004, p = 0.015) or the right middle lobe (p < 0.001) and severe extent of opacifications (p = 0.002). Multivariable analysis revealed crazy paving and severe extent of parenchymal involvement to be independently predictive for a poor outcome. CONCLUSIONS: Easy to assess CT features in the early phase of disease independently predicted an adverse outcome of patients with COVID-19 pneumonia.

Signal intensity in the dentate nucleus after cumulative dose of Gd-EOB-DTPA: First results of a prospective longitudinal study.

Gadolinium ethoxybenzyl-diethylenetriaminepentaacetic acid (Gd-EOB-DTPA) is a hepatocyte-specific, linear ionic contrast agent for MRI. In comparison to other linear contrast agents Gd-EOB-DTPA is excreted equally through liver and kidneys. This prospective longitudinal study investigates the signal intensity (SI) in the dentate nucleus (DN) on unenhanced T1-weighted images after repetitive application of Gd-EOB-DTPA. 46 patients were included into the study and 107 MRI examinations were performed. Statistical analysis of 25 patients showed no significant correlation between cumulative dose of Gd-EOB-DTPA and SI change and between the DN/Pons ratiolast and the mean DN/Pons ratiofirst. Subgroup analysis however revealed a significant correlation for one out of two readers. Gd-EOB-DTPA deposition could not be proven in the framework of this study.

Color Coded Perfusion Imaging with Contrast Enhanced Ultrasound (CEUS) for Post-Interventional Success Control Following Irreversible Electroporation (IRE) of Primary and Secondary Malignant Liver Lesions.

AIM: Evaluation of the post-interventional success following irreversible electroporation (IRE) using a new color coded perfusion quantification software with contrast-enhanced ultrasound (CEUS) in patients with malignant lesions of the liver. METHODS: Thirty-eight patients with 68 malignant liver lesions underwent IRE. All malignant lesions were investigated with CEUS before and within 24 hours following IRE to detect residual tumor tissue. The parameters analyzed by color coded perfusion quantification software were: the peak enhancement (pE), time to peak (TTP), mean transit time (mTT), rise (Ri) and wash-in area under the curve (WiAUC). Perfusion in the center, the margins of the lesions and in the surrounding liver were evaluated using these parameters. RESULTS: Hepatocellular carcinoma (HCC) with complete ablation showed significantly different changes between the center and the margin of the lesions for WiAUC (p<0.05) and pE (p<0.01). Also significant differences were noted between the center of the lesions and the surrounded tissue for the same parameters (p<0.01). In the completely ablated metastatic lesions, significant differences were found between the center of the lesion and the margins (p < 0.01) and between the center of the lesion and the surrounding liver (p < 0.05) for WiAUC. mTT, TTP and Ri showed no significant changes between the center of the lesions, margin of the lesions or surrounding tissue. Also, no significant differences were found for these parameters in the different regions of interest for HCC or the metastatic lesions with partial ablation success. CONCLUSION: CEUS with perfusion imaging is a valuable supporting tool for the post-interventional evaluation of liver lesions following IRE. Focus should be placed on the peak enhancement (pE) and the wash-in area under the curve (WiAUC).

Color coded perfusion analysis and microcirculation imaging with contrast enhanced ultrasound (CEUS) for post-interventional success control following thermal ablative techniques of primary and secondary liver malignancies.

AIM: Evaluation of the post-interventional success following ablative techniques (radiofrequency and microwave) using a new color coded perfusion quantification software with CEUS in patients with primary and secondary liver malignancies. MATERIAL AND METHODS: 75 patients (60 males, 15 females, age 24-84 years, mean 62.7 years) with 128 malignant liver lesions were included in this study. Between 01/2013 and 06/2018, the therapeutic interventional procedure in 88 lesions was MWA, in 40 lesions RFA. All patients underwent CEUS using a convex multifrequency probe (1-6 MHz) following application of 1-2.4 ml sulphur hexaflouride microbubbles, before and within 24 hours following RFA and MWA to detect residual tumor tissue. Postprocessing of the stored DICOM loops from 15 sec up to 1 min using a perfusion quantification software regarding peak enhancement (pE), time to peak (TTP), mean transit time (MTT), rise time (Ri) and Wash-in area under the curve (WiAUC) in the center of the lesion, the border area and periphery was performed. RESULTS: In patients treated with RFA, pE differences between center of the lesion vs. surrounding liver were found to be statistically extremely significant (p < 0.001), differences between center of the lesion and margin were also statistically significant (p < 0.01). mTT, TTP, WiAuC and Ri showed no significant difference between center, margin or surrounding liver.In patients treated with MWA, statistically significant differences (p < 0.05) were found for pE, Ri and mTT regarding the differences between center of lesion and surrounding tissue. WiAuC and TTP showed no significant differences between center, margin or surrounding liver. CONCLUSION: CEUS with perfusion imaging is a valuable supporting tool for post-interventional success control following RFA and MWA of primary and secondary liver maligancies. Focus should be placed upon pE following MWA and pE, Ri and mTT following RFA.

Color coded perfusion imaging with contrast enhanced ultrasound (CEUS) for post-interventional success control following trans-arterial chemoembolization (TACE) of hepatocellular carcinoma.

AIM: Evaluation of an external color coded perfusion quantification software with CEUS for the post-interventional success control following TACE in patients with HCC. MATERIAL AND METHODS: 31 patients (5 females, 26 males, age range 34-82 years, mean 66.8 years) with 59 HCC lesions underwent superselective TACE using DSM Beads between 01/2015 and 06/2018. All patients underwent CEUS by an experienced examiner using a convex multifrequency probe (1-6 MHz) within 24 hours following TACE to detect residual tumor tissue. Retrospective evaluation using a perfusion quantification software regarding pE, TTP, mTT, Ri and WiAUC in the center of the lesion, the margin and surrounding liver. RESULTS: In all lesions, a post-interventional visual reduction of the tumor microvascularization was observed. Significant differences between center of the lesion vs. margin and surrounding liver were found regarding peak enhancement (867.8 ± 2416 center vs 2028 ± 3954 margin p<0.005) and center 867.8 ± 2416 vs 2824 ± 4290 surrounding liver, p<0.0001)). However, no significant differences were found concerning Ri, WiAuC, mTT and TTP. CONCLUSION: CEUS with color- coded perfusion imaging is a valuable supporting tool for post-interventional success control following TACE of liver lesions. Peak enhancement seems to be the most valuable parameter.

Characterization of Focal Liver Lesions using CEUS and MRI with Liver-Specific Contrast Media: Experience of a Single Radiologic Center.

AIM: The purpose of this study was to compare contrast-enhanced ultrasound (CEUS), magnetic resonance imaging (MRI) using liver-specific contrast agent and a combination of both for the characterization of focal liver lesions (FLL). METHODS: 83 patients with both benign and malignant liver lesions were examined using CEUS and MRI after the intravenous administration of liver-specific contrast media. All patients had inconclusive results from prior imaging examinations. Histopathological specimens could be obtained in 53 patients. Ultrasound was performed using a multi-frequency curved probe (1 - 6 MHz) after the injection of 1 - 2.4 ml ultrasound contrast media. The sensitivity, specificity, positive predictive value and negative predictive value of CEUS, MRI and a combination of both (CEUS + MRI) were compared. RESULTS: The sensitivity, specificity, positive and negative predictive values regarding lesion classification were 90.9 %, 70.6 %, 92.3 % and 66.6 %, respectively, for CEUS; 90.9 %, 82.4 %, 95.2 % and 70.0 %, respectively, for MRI; and 96.9 %, 70.6 %, 92.7 % and 85.7 % respectively, for CEUS + MRI. There were no statistically significant differences. 6 malignant lesions were missed using CEUS or MRI alone (false negatives). The use of both modalities combined reduced the false-negative results to 2. CONCLUSION: CEUS and MRI with liver-specific contrast media are very reliable and of equal informative value in the characterization of focal liver lesions. The number of false-negative results can be decreased using a combination of the two methods.

Analysis of Radiological Case Presentations and their Impact on Therapy and Treatment Concepts in Internal Medicine.

Purpose Evaluation of clinical impact regarding diagnostic and therapeutic changes influenced by interdisciplinary radiological case presentations. Materials and Methods Prospective evaluation of radiological-gastrointestinal clinical case conferences over a 1-year period at a tertiary care center. We documented the preparation (phase 1) and clinical case conference (phase 2) regarding their impact on the radiology report and further diagnostic work-up and therapy. Results 1067 examinations were evaluated in 69 clinical case conferences including 487 cases. We calculated a mean time of 35.8 minutes per conference with 5.1 minutes per case for preparation. During phase 1, major changes compared to the previous report were found in 1.2 % of cases, and no change was found in 91.4 % of cases. In phase 2 an additional relevant finding was found in 0.6 % of cases, while there was no major change to the reports in 99 % of cases. We recommended further radiological diagnostic workup in 9 % of cases and interventional radiological examination in 2.7 % of cases, while no change was documented in 83.2 %. Further radiological or surgical therapy was recommended in 7 % and 6.8 % of cases, respectively. There was no change in therapy in 78.5 % of cases. Conclusion The analysis of an interdisciplinary radiological case presentation in internal medicine shows that the case discussion with the radiologist results in a change in patient management in 37.3 % of cases (16.8 % diagnosis, 21.5 % therapy). Overall, interdisciplinary radiological clinical case conferences help to improve the management and quality of patient care. Our data support the broad implementation of radiological clinical case conferences. Key Points · The second opinion obtained during the preparation of a radiological case presentation does not change the written report in most cases.. · "Talking radiology" in radiological case presentations results in a significant change in patient management in over ⅓ of all cases.. · In radiological clinical case conferences an experienced radiologist can initiate diagnostic and interventional radiological methods that can be correctly implemented in therapeutic pathways.. · "Talking radiology" improves the quality of therapy and patient care.. Citation Format · Dendl L. M., Teufel A., Schleder S. et al. Analysis of Radiological Case Presentations and their Impact on Therapy and Treatment Concepts in Internal Medicine. Fortschr Röntgenstr 2017; 189: 239 - 246.

Retinal Involvement in a Patient with Cerebral Manifestation of Chronic Graft-Versus-Host-Disease.

BACKGROUND: We report a 35-year-old female patient with cerebral manifestations of chronic graft-versus-host disease (cGvHD) and putative retinal involvement after allogeneic peripheral blood stem cell transplantation (alloHSCT). PATIENT AND METHODS: The patient experienced recurrent episodes of fever and encephalitic signs 7 months after alloHSCT during taper of immunosuppression (IS). RESULTS: Cerebral magnetic resonance imaging (MRI) showed non-gadolinium-enhancing confluent periventricular lesions and cerebrospinal fluid inflammation. After exclusion of infectious causes, treatment with steroids and antiepileptics improved cognitive deficits. Steroid reduction provoked a relapse responding to IS. 2 years later, she complained of right-sided blurred vision and floaters; both eyes showed whitish circumscribed retinal infiltrations, cellular infiltration of the vitreous and mild bilateral optic disc edema. Oncological and neurological work-up ruled out infectious diseases and other GvHD manifestations. Symptoms and signs resolved under continued systemic IS, leaving pigmented retinal scars. After IS withdrawal, classical cutaneous cGvHD developed, resolving on systemic IS. 94 months after transplantation, she is doing well. CONCLUSION: To our knowledge, this is the first observation of retinal involvement of cerebral cGvHD manifestations with retinal infiltrations documented in the absence of other causes and in parallel to periventricular lesions in cerebral MRI. Based on bone marrow histology, we discuss a small vessel pathophysiology of cGvHD.

Is Strain Elastography (IO-SE) Sufficient for Characterization of Liver Lesions before Surgical Resection--Or Is Contrast Enhanced Ultrasound (CEUS) Necessary?

AIM: To evaluate the diagnostic accuracy of IO-SE in comparison to IO-CEUS for the differentiation between malignant and benign liver lesions. MATERIAL AND METHODS: In a retrospective diagnostic study IO-CEUS and SE examinations of 49 liver lesions were evaluated and compared to histopathological examinations. Ultrasound was performed using a multifrequency linear probe (6-9 MHz). The loops of CEUS were evaluated up to 5 min. The qualitative characterization of IO-SE was based on a color coding system (blue = hard, red = soft). Stiffness of all lesions was quantified by a specific scaling of 0-6 (0 = low, 6 = high) using 7 ROIs (2 central, 5 peripheral). RESULTS: All malignant lesions displayed a characteristic portal venous washout and could be diagnosed correctly by IO-CEUS. 3/5 benign lesions could not be characterized properly either by IO-CEUS or IO-SE prior to resection. Thus for IO-CEUS sensitivity, specificity, positive and negative predictive value and accuracy were 100%, 40%, 94%, 100% and 94%. Lesion sizes were between 8 and 59 mm in diameter. Regarding the IO-SE, malignant lesions showed a marked variability. In qualitative analysis, 31 of the malignant lesions were blue colored denoting overall induration. Thirteen malignant lesions showed an inhomogenous color pattern with partial indurations. Two of the benign lesions also displayed overall induration. The other benign lesions showed an inhomogenous color mapping. Calculated sensitivity of the SE was 70.5%, specificity 60%, PPV 94%, NPV 18.75%, and accuracy 69%. CONCLUSION: IO-CEUS is useful for localization and characterization of liver lesions prior to surgical resection whereas IO-SE provided correct characterization only for a limited number of lesions.