Jürgen K. Willmann

Detection of submucosal gastric fundal varices with multi-detector row CT angiography

Background and aim: The diagnosis of submucosal fundal varices is challenging. Currently, endoscopy and endoscopic ultrasound (EUS) are considered most useful for this purpose. The aim of this study was to evaluate if multi-detector row CT (MDCT) angiography contributes to the diagnosis of submucosal fundal varices. Patients and methods: Twenty two patients with endoscopically suspected fundal varices were prospectively included in the study. All patients underwent EUS and MDCT angiography. Levels of agreement between EUS and MDCT angiography for the detection of submucosal and perigastric fundal varices were evaluated by three blinded independent readers. In addition, variceal size and location, as well as afferent and efferent vessels of the submucosal varices, were determined. Results: Good or excellent image quality of MDCT angiography was obtained in 21/22 patients (95%). Based on EUS, submucosal varices were detected in 16 of 22 patients (73%) and perigastric varices in 22/22 patients (100%). Using MDCT angiography, the presence of submucosal varices was confirmed in all of these 16 patients by all three readers. Perigastric varices were also confirmed in all 22 patients by all three readers. In addition, all three readers noted the presence of a submucosal varix in an additional patient which was not detected on initial EUS. MDCT angiography showed an excellent interobserver reliability with regard to variceal diameter (κ=0.90) and variceal location (κ=0.94). Based on MDCT angiography, afferent and efferent vessels of submucosal varices included the left gastric vein in 11 (65%), the posterior/short gastric veins in 15 (88%), gastrorenal shunts in 10 (59%), the left inferior phrenic vein in six (35%), and the left pericardiophrenic vein in six (35%) of 17 patients. Conclusions: MDCT angiography is equivalent to EUS in terms of detection and characterisation of fundal varices, in particular with regard to the distinction between submucosal and perigastric fundal varices.

Traumatic injuries: imaging of abdominal and pelvic injuries.

Abstract. The availability of new imaging modalities has altered the diagnostic approach to patients with abdominal and pelvic trauma. Computed tomography and ultrasound have largely replaced diagnostic peritoneal lavage. Ultrasound is used in most trauma centers as the initial imaging technique for the detection of hemoperitoneum and helps to determine the need for emergency laparotomy. Computed tomography allows for an accurate diagnosis of a wide range of traumatic abdominal and pelvic conditions. The speed of single-detector helical and multi-detector row CT (MDCT) permits a rapid CT examination of the seriously ill patient in the emergency room. In particular, the technology of MDCT permits multiple, sequential CT scans to be quickly obtained in the same patient, which is a great advance in the rapid assessment of the multiple-injured patient. The evolving concepts in trauma care promoting non-operative management of liver and splenic injuries creates the need for follow-up cross-sectional imaging studies in these patients. Computed tomography and, less frequently, MR or ultrasound, are used for this purpose.

ECG-gated multi-detector row CT for assessment of mitral valve disease: initial experience

Abstract. Our objective was to evaluate applicability and image quality of contrast-enhanced, retrospectively ECG-gated multi-detector row CT (MDCT) for visualization of anatomical details of the mitral valve and its apparatus, and to determine the value of MDCT for diagnosing abnormal findings of the mitral valve. Twenty consecutive patients with mitral valve disease underwent MDCT preoperatively. Two readers assessed visibility of the mitral valve annulus, mitral valve leaflets, tendinous cords, and papillary muscles by using a four-point Likert grading scale. Abnormal mitral valve findings [thickening of the mitral valve leaflets, presence of mitral annulus calcification (MAC), and calcification of the valvular leaflets] were compared with preoperative echocardiography and intraoperative findings. Visibility of the mitral valve annulus and mitral valve leaflets was good or excellent in 15 patients (75%) and in 19 patients (95%) for papillary muscles. The MDCT yielded a 95–100% agreement compared with echocardiography and surgery with regard to the assessment of mitral valve leaflet thickening and the presence of calcifications of the mitral valve annulus or mitral valve leaflets. Intermodality agreement between MDCT and echocardiography was excellent with regard to classification of mitral valve leaflet thickness (κ=1.00) and good regarding classification of MAC thickness (κ=0.73). Contrast-enhanced, retrospectively ECG-gated MDCT allows good to excellent visualization of anatomical details of the mitral valve and its apparatus, and demonstrates good agreement with echocardiography and surgery in diagnosing mitral valve abnormalities.

Multidetector-row helical CT: analysis of time management and workflow

Abstract. The purpose of this study was to evaluate time management and workflow for multidetector-row helical CT (MDCT). Time for patient and data handling of at total of 580 patients were evaluated at two different time periods (December 1999, August 2000), each for the following baseline measurements: (a) change of clothes/instruction; (b) patient placement on the CT table/i.v. catheter; (c) CT planning and programming; (d) CT data acquisition; (e) CT data reconstruction; (f) CT data storage/printing. All imaging was performed on a Somatom Volume Zoom (Siemens, Erlangen, Germany). Time measurements summarized for different CT protocols revealed the following: (a) 5:01xa0min (±2.06xa0min); (b) 4:36xa0min (±2.43xa0min); (c) 4:11xa0min (±2.55xa0min); (d) 0:43xa0min (±0.15xa0min); (e) 6:59xa0min (±2.39xa0min); (f) 09:51xa0min (±3.51xa0min). Planning and programming was most time-consuming for CT angiography, whereas chest and abdominal CT needed only 3:26 and 3:30xa0min, respectively. Reconstruction time was highest for HRCT (9:22xa0min) and CTA (9:03xa0min). Data storage/printing was most time-consuming for HRCT (13:02xa0min), followed by combined neck–chest–abdomen examinations (12:19xa0min). Comparing the two time periods, during which a software update was performed, a mean time reduction of 4:31xa0min per patient (15%, p<0.001) was achieved. Whereas CT data acquisition time is no longer a problem with MDCT, patient management, data reconstruction, and data storage are the most time-consuming parts. Well-trained technicians, state-of-the-art workstations, and fast networking are the most important factors to improve workflow.

Spiral-CT angiography to assess feasibility of endovascular aneurysm repair in patients with ruptured aortoiliac aneurysm

BACKGROUNDnTo evaluate spiral computed tomography (SCT) angiography for assessment of feasibility of endovascular aneurysm repair (EVAR) in patients with ruptured aortoiliac aneurysm (AAA).nnnPATIENTS AND METHODSn24 patients (mean age 74 years; range, 69 to 82 years) with suspicion of ruptured AAA and stable hemodynamics were preoperatively examined by using a SCT scanner in the emergency room. SCT angiography was performed from the suprarenal aorta to the femoral bifurcation after a fixed injection delay time of 30 seconds. After that a venous phase SCT scan, beginning at the last image position and ending at the upper thoracic aperture, was performed.nnnRESULTSnThe mean acquisition time of the SCT scan was 80 seconds (range 70 to 100 seconds), the mean overall procedure time, including image reconstruction, 5 minutes (range, 4 to 6 minutes). 2D images were directly evaluated during CT data acquisition, and 3D image reconstructions within 10 minutes (range, 8 to 11 minutes) after the SCT scan. AAA rupture was assessed in 14/24 patients (58%): in 10/14 patients (71%) rupture was contained to the retroperitoneum, and in 4/14 patients (29%) intraperitoneal rupture was observed. Successful EVAR was performed in 6/14 patients (43%) with ruptured AAA, and in 8/10 patients (80%) without ruptured AAA. Open surgery was exclusively performed in 6/24 patients (25%) with inappropriate anatomy for EVAR and in 4/24 patients (17%) with intraperitoneal rupture.nnnCONCLUSIONSnSpiral computed tomography angiography is a reliable technique to assess feasibility of endovascular aneurysm repair in patients with ruptured aortic aneurysm. However, it can only be recommended for patients with stable hemodynamics, despite of the short acquisition time.Background: To evaluate spiral computed tomography (SCT) angiography for assessment of feasibility of endovascular aneurysm repair (EVAR) in patients with ruptured aortoiliac aneurysm (AAA). Patients and methods: 24 patients (mean age 74 years; range, 69 to 82 years) with suspicion of ruptured AAA and stable hemodynamics were preoperatively examined by using a SCT scanner in the emergency room. SCT angiography was performed from the suprarenal aorta to the femoral bifurcation after a fixed injection delay time of 30 seconds. After that a venous phase SCT scan, beginning at the last image position and ending at the upper thoracic aperture, was performed. Results: The mean acquisition time of the SCT scan was 80 seconds (range 70 to 100 seconds), the mean overall procedure time, including image reconstruction, 5 minutes (range, 4 to 6 minutes). 2D images were directly evaluated during CT data acquisition, and 3D image reconstructions within 10 minutes (range, 8 to 11 minutes) after the SCT scan. AAA rupture...

Endotracheal neurofibroma in neurofibromatosis type 1: an unusual manifestation

Tracheal involvement is an extremely rare manifestation in patients with neurofibromatosis type 1 (NF-1). We present a 33-year-old women with NF-1 suffering from progressive dyspnea. Multislice spiral CT revealed a neurofibroma located within the trachea with intratracheal extension. To our knowledge, this is the first report of an intratracheal neurofibroma which has been documented by CT. This indicates that multislice spiral CT allows accurate demonstration of localization and extent of this rare manifestation of neurofibromas.

Secondary aortoenteric fistula: active bleeding detected with multi-detector-row CT.

Abstract. We report a case of active bleeding of a secondary aortoenteric fistula (SAEF), in which CT angiography with multi-detector-row CT (MDCT) was finally diagnostic after negative catheter angiography and unsatisfactory endoscopy. The MDCT angiography clearly demonstrated the fistulous tract between the abdominal aortic graft and the duodenum. The dynamic process of bleeding was confirmed as a net increase of contrast agent accumulation in the duodenum through different phases. The MDCT angiography with its excellent 3D image quality is therefore a valuable method in the assessment of active SAEF bleeding.

Adrenal angiomyolipoma in lymphangioleiomyomatosis

Sir, A 32-year-old woman with lymphangioleiomyomatosis (LAM) complained of diffuse abdominal pain. Contrast-enhanced multidetector row computed tomography (MDCT) showed a large retroperitoneal, fatcontaining, partially enhancing mass in the right adrenal space and in close contact with the right kidney (Fig. 1). To assess the adrenal localization of the mass, selective intraarterial digital subtraction angiography (DSA) was performed, which demonstrated a vascular supply of the mass through the right inferior suprarenal artery originating from a right accessory renal artery (Fig. 1). After laparoscopic adrenalectomy, an angiomyolipoma of the right adrenal gland was confirmed by histology. Adrenal angiomyolipoma in LAM is extremely rare. Only one case of a suspected adrenal angiomyolipoma in a patient with LAM has been reported in the literature but was neither documented radiologically nor confirmed by histology [1]. To the best of our knowledge, this is the first report of a histologically proven adrenal angiomyolipoma, documented by MDCT and DSA, in a patient with LAM. Extrapulmonary manifestations in patients with LAM have been reported in up to 76% of cases, of which the majority are angiomyolipomas. In most patients, angiomyolipomas are located in the kidneys; rarely, they have been found in the liver [2, 3]. Therefore, with the presence of multiple small angiomyolipomas in both kidneys, it was initially hypothesized that the mass in our patient may be an eccentric cortical manifestation of a large angiomyolipoma in the right kidney with extension into the right adrenal space. However, by demonstrating the arterial supply through the right inferior suprarenal artery, selective DSA proved the adrenal origin of the angiomyolipoma in this case. Because up to 52% of patients with angiomyolipomas larger than 4 cm are symptomatic and have an increased risk of bleeding, surgery or selective arterial embolization has been suggested in large angiomyolipomas. In the last years, laparoscopic adrenalectomy has been recommended because it is less invasive, with lower mortality compared with open surgery.

Spiral-CT Angiographie vor endovaskulärer Versorgung bei Patienten mit rupturiertem aortoiliakalem Aneurysma

BACKGROUNDnTo evaluate spiral computed tomography (SCT) angiography for assessment of feasibility of endovascular aneurysm repair (EVAR) in patients with ruptured aortoiliac aneurysm (AAA).nnnPATIENTS AND METHODSn24 patients (mean age 74 years; range, 69 to 82 years) with suspicion of ruptured AAA and stable hemodynamics were preoperatively examined by using a SCT scanner in the emergency room. SCT angiography was performed from the suprarenal aorta to the femoral bifurcation after a fixed injection delay time of 30 seconds. After that a venous phase SCT scan, beginning at the last image position and ending at the upper thoracic aperture, was performed.nnnRESULTSnThe mean acquisition time of the SCT scan was 80 seconds (range 70 to 100 seconds), the mean overall procedure time, including image reconstruction, 5 minutes (range, 4 to 6 minutes). 2D images were directly evaluated during CT data acquisition, and 3D image reconstructions within 10 minutes (range, 8 to 11 minutes) after the SCT scan. AAA rupture was assessed in 14/24 patients (58%): in 10/14 patients (71%) rupture was contained to the retroperitoneum, and in 4/14 patients (29%) intraperitoneal rupture was observed. Successful EVAR was performed in 6/14 patients (43%) with ruptured AAA, and in 8/10 patients (80%) without ruptured AAA. Open surgery was exclusively performed in 6/24 patients (25%) with inappropriate anatomy for EVAR and in 4/24 patients (17%) with intraperitoneal rupture.nnnCONCLUSIONSnSpiral computed tomography angiography is a reliable technique to assess feasibility of endovascular aneurysm repair in patients with ruptured aortic aneurysm. However, it can only be recommended for patients with stable hemodynamics, despite of the short acquisition time.Background: To evaluate spiral computed tomography (SCT) angiography for assessment of feasibility of endovascular aneurysm repair (EVAR) in patients with ruptured aortoiliac aneurysm (AAA). Patients and methods: 24 patients (mean age 74 years; range, 69 to 82 years) with suspicion of ruptured AAA and stable hemodynamics were preoperatively examined by using a SCT scanner in the emergency room. SCT angiography was performed from the suprarenal aorta to the femoral bifurcation after a fixed injection delay time of 30 seconds. After that a venous phase SCT scan, beginning at the last image position and ending at the upper thoracic aperture, was performed. Results: The mean acquisition time of the SCT scan was 80 seconds (range 70 to 100 seconds), the mean overall procedure time, including image reconstruction, 5 minutes (range, 4 to 6 minutes). 2D images were directly evaluated during CT data acquisition, and 3D image reconstructions within 10 minutes (range, 8 to 11 minutes) after the SCT scan. AAA rupture...

Functional Ureteral Obstruction due to Complex Pelvic Venous Anomaly

Venous anomalies are rare causes of ureteral obstruction. We report the case of a 31-year-old woman with obstruction of the right distal ureter by a complex pelvic venous anomaly. Beside benign and malignant lesions of the retroperitoneum, venous anomalies should also be considered in the differential diagnosis of extrinsic ureteral obstruction. Due to its abilities of three-dimensional visualization, multi-detector row computed tomography is helpful in the depiction of venous anomalies.