Klaus Hergan

Drug smuggling by body packing: what radiologists should know about it

Body packing is a distinct method for smuggling drugs. What radiologists need to know is discussed in this pictorial review. Radiologists are confronted with diagnostic imaging of body packers because of two main reasons: complications of body packing and identifying drug packets within the gastrointestinal tract. The standard examination used is plain X-ray of the abdomen in an upright and a supine position. Computed tomography is occasionally used but nevertheless described as a very accurate diagnostic tool. Ultrasound and MR imaging do not play an important role in that field. Depending on the purity of the drug, three different forms of attenuation have been described: hashish is denser than stool; cocaine appears similar to stool; and heroin has a gaseous transparence. The packets are of a round to oval form, usually of a particular uniformity and rarely confused with scybala if arranged like a pearl chain; therefore, plain X-ray is the method of choice to detect drug-filled packets within the gastrointestinal tract of body packers.

ECG-Triggered Non-Contrast-Enhanced MR Angiography (TRANCE) versus Digital Subtraction Angiography (DSA) in patients with peripheral arterial occlusive disease of the lower extremities

ObjectiveTo prospectively determine the diagnostic value of electrocardiography-triggered non-contrast-enhanced magnetic resonance angiography (TRANCE) of the lower extremities including the feet versus DSA.MethodsAll 43 patients with symptomatic peripheral arterial occlusive disease (PAOD) underwent TRANCE before DSA. Quality of MRA vessel depiction was rated by two independent radiologists on a 3-point scale. Arterial segments were graded for stenoses using a 4-point scale (grade 1: no stenosis; grade 2: moderate stenosis; grade 3: severe stenosis; grade 4: occlusion). Findings were compared with those of DSA.ResultsIn the 731 vessel segments analysed, intra-arterial DSA revealed 283 stenoses: 33.6% moderate, 16.6% severe and 49.8% occlusions. TRANCE yielded a mean sensitivity, specificity, positive and negative predictive value and diagnostic accuracy to detect severe stenoses or occlusions of 95.6%, 97.4%, 87.2%, 99.2%, 97.1% for the thigh segments and 95.2%, 87.5%, 83.2%, 96.6%, 90.5% for the calf segments. Excellent overall image quality was observed for TRANCE in 91.4% versus 95.7% (DSA) for the thigh and in 60.7% versus 91.0% for the calves, while diagnostic quality of the pedal arteries was rated as insufficient.ConclusionTRANCE achieves high diagnostic accuracy in the thigh and calf regions, whereas the pedal arteries showed limited quality.

Insula-Specific 1H Magnetic Resonance Spectroscopy Reactions in Heavy Smokers under Acute Nicotine Withdrawal and after Oral Nicotine Substitution

The aim of this study was to clarify whether addiction-specific neurometabolic reaction patterns occur in the insular cortex during acute nicotine withdrawal in tobacco smokers in comparison to nonsmokers. Fourteen male smokers and 10 male nonsmokers were included. Neurometabolites of the right and the left insular cortices were quantified by magnetic resonance spectroscopy (MRS) on a 3-Tesla scanner. Three separate MRS measurements were performed in each subject: among the smokers, the first measurement was done during normal smoking behavior, the second measurement during acute withdrawal (after 24 h of smoking abstinence), and the third shortly after administration of an oral nicotine substitute. Simultaneously, craving, withdrawal symptoms, and CO levels in exhaled air were determined during the three phases. The participants in the control group underwent the same MR protocol. In the smokers, during withdrawal, the insular cortex showed a significant increase in glutamine (Gln; p = 0.023) as well as a slight increase not reaching significance for glutamine/glutamate (Glx; p = 0.085) and a nonsignificant drop in myoinositol (mI; p = 0.381). These values tended to normalize after oral nicotine substitution treatment, even though differences were not significant: Gln (p = 0.225), Glx (p = 0.107) and mI (p = 0.810). Overall, the nonsmokers (control group) did not show any metabolic changes over all three phases (p > 0.05). In smokers, acute nicotine withdrawal produces a neurometabolic reaction pattern that is partly reversed by the administration of an oral nicotine substitute. The results are consistent with the expression of an addiction-specific neurometabolic shift in the brain and confirm the fact that the insular cortex seems to play a possible role in nicotine dependence.

Differential Diagnosis of Lemierre's Syndrome in a Patient with Acute Paresis of the Abducens and Oculomotor Nerves

Lemierres syndrome is characterized by anaerobic septicemia, internal jugular vein thrombosis, and septic emboli associated with infections of the head and neck. We describe an unusual and clinically confusing case of a young woman with an acute paresis of the abducens nerve and partial paresis of the right oculomotor nerve. After an extensive imaging diagnostic procedure, we also documented a peritonsillar abscess and various types of thromboses in intracranial and extracranial veins. Furthermore, we found brain and lung abscesses, which led us to establish the diagnosis of Lemierres syndrome. Despite intensive anti-coagulation and antibiotic therapy, the patient developed a mycotic aneurysm in the right internal carotid artery directly adjacent to the previously thrombosed cavernous sinus. In summary, we were able to confirm that Lemierres syndrome may occur in conjunction with uncharacteristic symptoms. Due to the sometimes confusing clinical symptoms as well as clinical and radiological specialties, we had to work on an interdisciplinary basis to minimize the delay prior to establishing the diagnosis and therapy.

Secondary Malignant Peritoneal Mesothelioma of the Greater Omentum after Therapy for Primary Pleural Mesothelioma

Mesothelioma is the most common malignant primary tumor of the pleura and usually associated with inhalation of asbestos fibers. In contrast, peritoneal mesothelioma is a rare entity whose pathomechanism is not yet fully understood. The coexistence of pleural mesothelioma with secondary involvement of the abdominal cavity has not been addressed in the literature. In this case report, we describe secondary malignant mesothelioma of the greater omentum. A 69-year-old man with histologically proven pleural mesothelioma on the right side and no past medical history of asbestos exposure received palliative treatment consisting of a talc pleurodesis. After a 6-month interval of stable disease, a local progressive tumor of the right pleura was seen on a CT scan. Eleven months later, during follow-up, the patient presented at our emergency department with a sudden onset of diffuse abdominal pain. Abdominal ultrasound revealed a mass within the greater omentum and the coexistence of free fluid. Subsequent abdominal CT scans demonstrated tumor infiltration from the right pleura by a transdiaphragmatic route into the abdomen, where diffuse infiltration of the greater omentum was observed. Aspiration of the ascites and the biopsy of the greater omentum confirmed the diagnosis of secondary malignant mesothelioma of the peritoneum. In conclusion, we present the extremely rare diagnosis of secondary malignant mesothelioma of the abdomen, which arose as a result of local progression from the right pleura into the abdomen.

Direct communication between radiologists and patients following imaging examinations. Should radiologists rethink their patient care

ObjectivesTo investigate patients’ perception of the radiology service when the radiologist communicates the findings to patients.MethodsAfter routine MRI, patients in group 1 (n = 101) were given the opportunity to discuss the findings with the radiologist. Patients in group 2 (n = 101) left the radiology department without any personal communication. Subsequently, by means of a questionnaire designed by an expert psychologist, both groups were asked regarding their anxiety, emotional attachment to the institute and subjective assessment of competence.ResultsOverall 76 % of all patients were concerned about their imaging findings without significant difference between both groups (p = 0.179). Significantly more patients in group 1 (81%) versus group 2 (14%; p < 0.001) perceived the opportunity to discuss their imaging findings with a radiologist to be a characteristic of a good radiology consultation. A larger number of patients in group 1 experienced significantly higher bonding and only wanted in the future to be examined in the department with communication (p = 0.001) (93%/75%). Significantly more patients in group 1 regarded the radiology department they attended as being more competent (mean score 4.72/4.09, p < 0.001).ConclusionDirect communication of imaging findings from radiologists to patients after an MRI examination leads to increased confidence in the radiology service and higher bonding between the patient and radiologist. Radiologists who refrain from direct communication have a lower bonding to patients and are assessed to have lower competence from the patient’s point of view.Key Points• Communication between radiologists and patients leads to an increased bonding affinity.• Direct communication leads to increased patient confidence in the radiology service.• Patients perceived discussion with a radiologist of high value.

Can Cut-Off-Values for Tumor Size or Patient Age in Breast Ultrasound Reduce Unnecessary Biopsies or is it all About Bi-rads?– A Retrospective Analysis of 763 Biopsied T1-Sized Lesions

AIMS AND OBJECTIVES To assess whether it is possible to establish a size cut-off-value for sonographically visible breast lesions in a screening situation, under which it is justifiable to obviate a biopsy and to evaluate the grayscale characteristics of the identified lesions. MATERIALS AND METHODS Images of sonographically visible and biopsied breast lesions of 684 patients were retrospectively reviewed and assessed for the following parameters: size, shape, margin, lesion boundary, vascularity, patients age, side of breast, histological result, and initial BI-RADS category. Statistical analyses (t-test for independent variables, ROC analyses, binary logistic regression models, cross-tabulations, positive/negative predictive values) were performed using IBM SPSS (Version 21.0). RESULTS Of all 763 biopsied lesions, 223 (29.2%) showed a malignant histologic result, while 540 (70.8%) were benign. Although we did find a statistically significant correlation of malignancy and lesion size (p=0.031), it was not possible to define a cut-off value, under which it would be justifiable to obviate a biopsy in terms of sensitivity and specificity (AUC: 0.558) at any age. Lesions showing the characteristics of a round or oval shape, a sharp delineation and no echogenic rim (n=112) were benign with an NPV of 99.1%. CONCLUSION It is not possible to define a cut-off value for size or age, under which a biopsy of a sonographically visible breast lesion can be obviated in the screening situation. The combination of the 3 grayscale characteristics, shape (round or oval), margin (circumscribed) and no echogenic-rim sign, showed an NPV of 99.1%. Therefore, it seems appropriate to classify such lesions as BI-RADS 2.

Suction/Inspiration against resistance or standardized Mueller maneuver : a new breathing technique to improve contrast density within the pulmonary artery: a pilot CT study

ObjectiveOur aim was to prospectively investigate whether the recently introduced suction/inspiration against resistance breathing method leads to higher computed tomography (CT) contrast density in the pulmonary artery compared to standard breathing.Material and methodsThe present study was approved by the Medical Ethics committee and all subjects gave written informed consent. Fifteen patients, each without suspicious lung emboli, were randomly assigned to four different groups with different breathing maneuvers (suction against resistance, Valsalva, inspiration, expiration) during routine CT. Contrast enhancement in the central and peripheral sections of the pulmonary artery were measured and compared with one another.ResultsPeripheral enhancement during suction yielded increased mean densities of 138.14 Hounsfield units (HU) (p = 0.001), compared to Valsalva and a mean density of 67.97 HU superior to inspiration (p = 0.075). Finally, suction in comparison to expiration resulted in a mean increase of 30.51 HU (p = 0.42). Central parts of pulmonary arteries presented significantly increased enhancement values (95.74 HU) for suction versus the Valsalva technique (p = 0.020), while all other mean densities were in favour of suction (versus inspiration: p = 0.201; versus expiration: p = 0.790) without reaching significance.ConclusionSuction/Inspiration against resistance is a promising technique to improve contrast density within pulmonary vessels, especially in the peripheral parts, in comparison to other breathing maneuvers.Key Points• Suction/Inspiration against resistance is promising to improve contrast density within the pulmonary artery.• Patients potentially suffering pulmonary embolism are able to follow suction/inspiration against resistance.• Contrast density after suction is superior in comparison to other breathing maneuvers.

Displacement of Malignant Cells into the Portal Triad of the Liver Results in Reduced Liver Perfusion, Mimicking Segmental Fatty Liver

Liver steatosis is often observed in different clinical situations. Oncological patients undergoing systemic therapy often develop liver steatosis, which can be diagnosed with normal routine scans such as CT and ultrasound. In this case report, we show that an isolated infiltration of the portal triad with tumor cells could mimic a fatty-like infiltration of the liver. Radiologists and clinicians should be aware of this pitfall and should perform a biopsy in cases of doubt.