J. Malms

Reliability and Validity of Noninvasive Imaging of Internal Carotid Artery Pseudo-Occlusion

BACKGROUND AND PURPOSE Our study evaluated noninvasive tests for the diagnosis of atheromatous internal carotid artery (ICA) pseudo-occlusion. METHODS Twenty patients (17 men, 3 women; mean age +/-SD, 64.3+/-11.6 years) with angiographically proven atheromatous ICA pseudo-occlusion (20 vessels) were prospectively examined with MR angiography (MRA; 2D and 3D time-of-flight techniques), color Doppler-assisted duplex imaging (CDDI) and power-flow imaging (PFI) with and without an intravenous ultrasonic contrast agent. As a control group, 13 patients (13 men; mean+/-SD age, 63.0+/-9.0 years) with angiographically proven ICA occlusion (13 vessels) were studied with the same techniques. For the determination of interobserver agreement (kappa statistics), the findings of each diagnostic technique were read by 2 blinded and independent observers who were not involved in patient recruitment and initial data acquisition. Specificity and sensitivity were calculated for all noninvasive techniques (observer consensus) in comparison to the standard of reference (intra-arterial angiography). RESULTS Interobserver reliabilities were kappa=0.86 for intra-arterial angiography, kappa=0.90 for unenhanced CDDI, kappa=0. 93 for enhanced CDDI, kappa=0.93 for unenhanced PFI, kappa=1.0 for enhanced PFI, kappa=0.93 for 2D MRA, and kappa=0.77 for 3D MRA, respectively (P<0.0001). Specificities and sensitivities were 0.92 and 0.70 for unenhanced CDDI, 0.92 and 0.83 for enhanced CDDI, 0.92 and 0.95 for unenhanced PFI, 1.0 and 0.94 for enhanced PFI, 1.0 and 0.65 for 2D MRA, and 0.89 and 0.47 for 3D MRA, respectively. CONCLUSIONS Advanced ultrasonographic techniques, especially PFI (with only 1 false-positive diagnosis of occlusion in the present series), can provide reliable and valid data to differentiate between ICA pseudo-occlusion and complete occlusion. In contrast, time-of-flight MRA at its present state is not capable of predicting minimal residual flow within a nearly occluded ICA.

Noninvasive investigation for renal artery stenosis : Contrast-enhanced magnetic resonance angiography and color Doppler sonography as compared to digital subtraction angiography

Introduction: The question about the most appropriate non-invasive method for detecting a renal artery stenosis (RAS) when comparing contrast enhanced magnetic resonance angiography (MRA) and color Doppler sonography (CDS) is still under discussion. Therefore we conducted a prospective study in order to evaluate both methods as compared to digital subtraction angiography (DSA). Patients/Methods: Thirtysix consecutive patients (53,9±13,7 years) with suspected RAS were investigated. MRA was performed using gadolinium for contrast enhancement. CDS was performed using a 2.5 and 3,5 MHz transducer. A peak systolic velocity (Vmax) >200 cm/sec within renal arteries and/or a side to side difference of the resistive index (RI) of >0,05 were used to discriminate stenosis. A diameter reduction of ≥60% by DSA was considered a stenosis relevant to the patient. Results: Sixtyeight main renal arteries and 9 accessory vessels were detected by DSA. Twenty main and 3 accessory arteries were found to be stenosed ≥60%, while 4 main and 1 accessory artery presented with occlusion. MRA detected 70 renal vessels (65 main and 5 accessory arteries). Twentyone stenosed arteries and 4 occluded vessels were correctly diagnosed by MRA. With CDS 68 renal vessels (62 main and 6 accessory arteries) could be visualized out of which 21 stenoses were diagnosed because of increased Vmax and 6 stenoses were detected because of a side to side difference of RI. For main renal arteries sensitivities and specificities were 96% and 86% for MRA and 96% and 89% for CDS. Conclusions: MRA and CDS are both comparable methods for detection of a renal artery stenosis ≥60%. Despite several limitations, CDS can at the moment still be favored as a screening method.

Venous incompetence in erectile dysfunction: evaluation with color-coded duplex sonography and cavernosometry/-graphy

Abstract. The purpose of this study was to assess the accuracy of multi-parameter measurements with color-coded duplex sonography (CCDS) for the diagnosis of venous leakage in patients with erectile dysfunction. Sixty patients with repeated unsatisfactory reactions after intracavernous injection of vasoactive substances underwent CCDS. Following intracavernous injection of prostaglandin E1, peak systolic velocity (PSV), enddiastolic velocity (EDV), time averaged velocity (TAV), resistance index (RI), and pulsatility index (PI) were measured in the cavernous arteries over 30 min (one measurement per minute). The results were compared with independent measurements based on dynamic pharmaco-cavernosometry/cavernosography (DPCC). Dynamic pharmaco-cavernosometry/cavernosography revealed venous leakage in 33 patients. Of 48 patients with normal PSV ( > 25 cm/s), 25 had veno-occlusive dysfunction and the remainder presented normal venous function. No statistically significant differences between these groups were found in EDV, RI, and PI measurements. In contrast, differences in TAV were significant between patients with (mean 9.4 ± 4.6 cm/s) and without venous leakage (mean 5.5 ± 2.2 cm/s; p = 0.001). Analysis of relative frequencies revealed a broad overlap of EDV, TAV, RI, and PI measurements between both groups. Sensitivities and specificities determined from receiver-operating-characteristic curves were > 80 % and > 50 % for a TAV threshold of 5 cm/s, and an RI threshold of 1.0. Measurements of EDV, TAV, RI, and PI in patients with repeated unsatisfactory reactions on intracavernous prostaglandin injection are poor predictors of venous leakage and should not replace DPCC in the investigation of vasculogenic impotence.

B-Mode-Sonographie und moderne dopplersonographische Methoden bei Krankheiten der Schilddrüse und der Nebenschilddrüsen

ZusammenfassungDie wesentliche Innovation im Bereich der Ultraschalldiagnostik in den letzten Jahren ist die farbkodierte Duplexsonographie (FKDS). Sie ermöglicht eine Quantifizierung der Gewebevaskularisation sowie eine qualitative Beurteilung der Angioarchitektonik. Hierdurch ist der floride M. Basedow aufgrund seiner einzigartigen Hypervaskularisation zur farbduplexsonographischen Anhiebsdiagnose geworden. Die Abnahme der Mehrdurchblutung im Verlauf der Erkrankung kann als Verlaufsparameter eingesetzt werden. Entzünldich infiltrierte Areale bei Thyreoiditis sind ebenfalls hypervaskularisiert, jedoch weniger ausgeprägt als beim M. Basedow. Eine für klinische Zwecke ausreichende Differenzierung von Schilddrüsenknoten in benigne und maligne ist sonographisch bislang nicht möglich. Während die FKDS zur Detektion vergrößerter Nebenschilddrüsen ungeeignet ist, kann sie möglicherweise bei der Unterscheidung von anderen zervikalen Raumforderungen beitragen.SummaryColor-coded duplex sonography is the main innovation in diagnostic ultrasound in recent years. It allows quantification of tissue vascularity and appreciation of vascular morphology. Due to the unique thyroid hypervascularity in Graves’ disease this diagnosis can be made with color Doppler sonography alone. The decrease of vascularity during the course of disease is a relevant parameter throughout the follow-up. Hypervascularity is also observed within areas of inflammatory infiltration in thyroiditis, but the level is lower than in Graves’ disease. Sonographic differentiation of benign from malignant thyroid nodules is not possible yet. Color-coded duplex sonography is not useful in the initial detection of parathyroid masses, but may be helpful in distinguishing parathyroid lesions from other cervical masses.

Effect of acute intravenous ace-inhibition on the intrarenal doppler flow characteristics in hypertensive patients with and without unilateral renal artery stenosis.

Assessment of intrarenal doppler signals is of particular importance in screening for renal artery stenosis. We studied the effect of acute ACE-inhibition (1,25 mg enalaprilate i.v.) on intrarenal resistive indices in 10 hypertensive patients with unilateral renal artery stenosis versus 10 patients with essential hypertension. Any changes limited to poststenotic vessels could possibly improve the diagnostic value of duplex sonography. After ACE-inhibition a significant fall of the intrarenal Resistive Index occurred in both patient groups. In cases of unilateral renal artery stenosis we saw a tendency to an increased side difference of the Resistive Index due to a greater fall on the poststenotic side. Therefore a clear advantage of duplex scanning after acute ACE-inhibition due to a limited effect of enalaprilate on poststenotic vessels was not found. The results suggest that the vascular resistance and not only the degree of renal artery stenosis is of significance for the characteristics of the doppler signal.

Glomerulonephritis und malignes Lymphom

BACKGROUND The association of non-Hodgkins lymphoma with different types of glomerulonephritis is well-known for many years. Whereas in Hodgkins disease, minimal change glomerulonephritis is mainly observed, in non-Hodgkins lymphoma various forms of glomerulonephritis are found. PATIENTS AND RESULTS We describe 3 cases of non-Hodgkins lymphoma, which were associated with glomerulonephritis. Two cases of glomerulonephritis showed nephrotic syndromes, which improved by medicinal treatment. In 2 cases glomerulonephritis and non-Hodgkins lymphoma developed simultaneously. In a third lymphoma was followed by glomerulonephritis after 3 years. CONCLUSION Although the pathogenetic relationship between non-Hodgkins lymphoma and glomerulonephritis is not fully understood, the high number of reported cases yield interdependence. Lymphoma associated glomerulonephritis is found more often in men than in women. Low-grade non-Hodgkins lymphomas--especially chronic lymphatic leukemias--seem to develop glomerulonephritis more frequently than high-grade. The majority of non-Hodgkins lymphoma do not show any predisposition to a special type of glomerulonephritis, only in cutaneous lymphoma IgA-nephropathy predominates.Zusammenfassung□ HintergrundGleichzeitiges Vorkommen von malignen Lymphomen und verschiedenen Glomerulonephritisformen ist lange bekannt. Während aber die Hodgkinsche Erkrankung oft zusammen mit “Minimal-change”-Glomerulonephritis auftritt, finden sich bei den Non-Hodgkin-Lymphomen ganz unterschiedliche Glomerulonephritisformen.□ Patienten und ErgebnisseEs werden drei Fälle von Non-Hodgkin-Lymphomen mit unterschiedlichen Glomerulonephritiden beschrieben. Zwei Glomerulonephritiden gingen mit nephrotischem Syndrom einher, das sich unter symptomatischer Behandlung besserte. In zwei Fällen manifestierten sich Glomerulonephritis und Non-Hodgkin-Lymphom gleichzeitig, im dritten Fall trat die Glomerulonephritis erst drei Jahre nach der Lymphomdiagnose auf.□ SchlußfolgerungAus diesen und in der Literatur belegten Fällen läßt sich schließen, daß die Vielzahl beschriebener Syntropien für Abhängigkeiten zwischen Non-Hodgkin-Lymphomen und Glomerulonephritis spricht. Bei Männern scheint die Assoziation häufiger zu sein. Niedrigmaligne Non-Hodgkin-Lymphome, insbesondere chronische lymphatische Leukämien, gehen häufiger mit Glomerulonephritis einher als hochmaligne Formen. Selten weisen Non-Hodgkin-Lymphome eine Bevorzugung bestimmter Glomerulonephritistypen auf. Lediglich kutane Non-Hodgkin-Lymphome gehen häufiger mit IgA-Nephritiden einher. Die pathogenetischen Zusammenhänge einer Syntropie von malignen Lymphomen und Glomerulonephritiden sind allerdings bisher nur unzureichend geklärt.Summary□ BackgroundThe association of non-Hodgkin’s lymphoma with different types of glomerulonephritis is well-known for many years. Whereas in Hodgkin’s disease, minimal change glomerulonephritis is mainly observed, in non-Hodgkin’s lymphoma various forms of glomerulonephritis are found.□ Patients and ResultsWe describe 3 cases of non-Hodgkin’s lymphoma, which were assoicated with glomerulonephritis. Two cases of glomerulonephritis nephritis showed nephrotic syndromes, which improved by medicinal treatment. In 2 cases glomerulonephritis and non-Hodgkin’s lymphoma developed simultaneously. In a third lymphoma was followed by glomerulonephritis after 3 years.□ ConclusionAlthough the pathogenetic relationship between non-Hodgkin’s lymphoma and glomerulonephritis is not fully understood, the high number of reported cases yield interdependence. Lymphoma associated glomerulonephritis is found more often in men than in women. Low-grade non-Hodgkin’s lymphomas — especially chronic lymphatic leukemias — seem to develop glomerulonephritis more rrequently than high-grade. The majority of non-Hodgkin’s lymphoma do not show any predisposition to a special type of glomerulonephrits, only in cutaneous lymphoma IgA-nephropathy predominates.

Radiological assessment of extranodal lymphoma: spectrum of disease

ZusammenfassungUnter primärer extranodaler Lymphommanifestation im engen Sinne wird die primäre Organmanifestation eines malignen Lymphoms unter Ausschluß von Thymus, Milz, dem Waldeyerschen Rachenring, des Wurmfortsatzes und der Peyerschen Ileumplaques definiert. Im klinischen Alltag wird der Begriff jedoch auch für die sekundäre Organmanifestation einer lymphoproliferativen Grunderkrankung eingesetzt. Primär extranodale Lymphome sind überwiegend Non-Hodgkin-Lymphome; nur in ca. 1 % der Fälle manifestiert sich der Morbus Hodgkin primär extranodal. Bei den extranodalen NHL überwiegen die hochmalignen Formen. Wesentliche Ausnahme hiervon sind die vorwiegend niedrig malignen MALT-Lymphome. In der Vergangenheit wegen ihres langsamen und ortsständigen Tumorwachstums als Pseudolymphome betrachtet, sind sie erstmalig als eigene Entität in der „Revised-European-American-Lymphoma (REAL-)-Klassifikation“ von 1994 berücksichtigt worden. Die Häufigkeitsangaben schwanken für die primäre extranodale Manifestation zwischen < 10–25 %. Wesentlicher Grund hierfür ist die klassifikationsbedingte unterschiedliche Berücksichtigung extranodaler Regionen. Eine sekundäre Organbeteiligung durch ein NHL tritt in bis zu 40 % der Fälle im langfristigen Krankheitsverlauf primär nodaler Lymphome auf. Bei AIDS-Patienten, die an einem AIDS-assoziierten Lymphom erkranken, wird der sekundäre Organbefall in 85 % der Fälle häufig diagnostiziert. Der folgende Beitrag setzt sich mit der radiologischen Bildgebung extranodaler Lymphommanifestationen im thorakoabdominalbereich auseinander.SummaryPrimary extranodal lymphoma manifestation in the narrow sense is the term used to define the primary organ manifestation of a malignant lymphoma, excluding the thymus, spleen, Waldeyers tonsillar ring, the appendix and Peyers patches. However, in the clinical routine the term is also used for the secondary organ manifestation of underlying lymphoproliferative disease. Primary extranodal lymphomas are mainly non-Hodgkin lymphomas; there is primary extranodal manifestation of Hodgkins disease in only about 1 % of the cases. Among the extranodal NHL, the highly malignant forms predominate. A major exception is MALT lymphomas, which mainly show low slow growth. In the past, they were considered to be pseudolymphomas because of their slow and localized tumor growth. They were included as an entity of their own for the first time in the Revised European American Lymphoma (REAL) classification of 1994. The incidence data vary between < 10 % and 25 % for primary extranodal manifestation. The major reason for this is the difference in extranodal regions because of classification. Secondary organ involvment of an NHL occurs in up to 40 % of the cases in the long-term course of the disease in primary nodal lymphomas. Secondary organ involvment is frequently diagnosed in AIDS patients who develop an AIDS-related lymphoma (85 % of cases). The following contribution reports on the radiological imaging of extranodal lymphoma manifestation in the thoracoabdominal region.