Markus Kilbinger

Simulated flow pattern in massive pulmonary embolism: Significance for selective intrapulmonary thrombolysis

AbstractPurpose: The flow pattern in the central pulmonary arteries proximal to large pulmonary emboli was studied experimentally. The currents to which thrombolytic agents are exposed when administered via an intrapulmonary catheter were visualized in order to explain the lack of benefit of local versus systemic administration. Methods: By illumination of suspended microspheres, the flow pattern proximal to an obstructing embolus was visualized in an in vitro pulmonary arterial flow model. In six dogs massive pulmonary embolism was created. A pigtail catheter was positioned in the pulmonary artery immediately proximal to the central edge of the occluding embolus. To allow visualization of the local flow pattern, a small amount of contrast material (4 ml) was injected through the catheter at a high flow rate (25 ml/sec). The course of the radiopaque spot that emerged from the catheter tip within 160 msec was minitored with digital subtraction angiography at a frame rate of 12.5 frames/sec. In two dogs, the study was repeated after embolus fragmentation with the same catheter position. Results: The flow model study revealed formation of a vortex proximal to the occluding embolus. In vivo experiments showed that the radiopaque spot was whirled by the vortex proximal to the embolus and made only evanescent contact with the edge of the embolus. Regardless of the embolus location, the contrast spot was washed into the non-occluded ipsilateral and contralateral pulmonary arteries within 0.40–0.64 sec. After embolus fragmentation, the contrast spot was carried completely into the formerly occluded artery. Conclusion: Flow studies explain why thrombolytic agents administered via a catheter positioned adjacent to the embolus may have no more effect than systemically administered agents. An enhanced local effect is precluded by the rapid washout into the non-occluded pulmonary arteries and subsequent systemic dilution. These results support the practice of direct intrathrombic injection of thrombolytics or local thrombolysis as an adjunct to embolus fragmentation.

Fragmentation of pulmonary emboli : In vivo experimental evaluation of two high-speed rotating catheters

Purpose:To test two over-the-wire systems for fragmentation of pulmonary emboli.Methods:In 11 dogs, 22 embolic occlusions of lobar or central pulmonary arteries were performed by injection of preformed emboli through a jugular vein sheath. A commercially available device (thrombolizer) and a modified version of the impeller catheter were introduced via the femoral vein and positioned at the embolus site.Results:Catheter placement at the site of the emboli was possible. In more than half of the cases a hydrophilic or an extra-stiff guidewire was necessary. The thrombolizer did not rotate properly with its original pneumatic drive and required a major modification. When sufficient rotation was provided, both fragmentation catheters were able to clear the occluded main arteries. Side branches were partly obstructed by the resulting fragments. Recanalization led to a reduction of the emboli-induced elevation of the pulmonary arterial pressure by two-thirds. Histology of the recanalized pulmonary artery segments revealed localized (impeller catheter) and widespread (thrombolizer) periarterial hemorrhage.Conclusion:Embolus fragmentation led to a hemodynamic improvement. The impeller catheter was less traumatic compared with the thrombolizer, which was technically insufficient.

Detection and compensation of rib structures in chest radiographs for diagnostic assistance

We developed a new method to compensate the rib structures in digital x-ray images. The intrinsic information of rib structures is eliminated and a higher image quality for the diagnosis of pulmonal structures is achieved. An essential task of the algorithm is the robust detection of the rib borders. In this paper we introduce three algorithms to perform this task. The first, introduced by Schreckenberg and Joswig, uses the hough transform to find rib borders, the second one uses a synergetic classifier to estimate the matching between rib edge templates and rib borders. The last one, the sinking lead algorithm, gives the best classification results by performing a matched template technique in combination with partial methods from the former two algorithms.

Bedside Testing (SimpliRED) in the Diagnosis of Deep Vein Thrombosis: Evaluation of 250 Patients

RATIONALE AND OBJECTIVES The authors evaluate the sensitivity and specificity of a bedside test (SimpliRED) in the diagnosis of deep vein thrombosis compared with contrast phlebography. METHODS Two hundred fifty patients, referred for phlebography, underwent bedside testing for detection of deep vein thrombosis. Contrast phlebography was performed immediately afterward. SimpliRED provides a clearly visible agglutination of the patients red blood cells in the presence of elevated levels of cross-linked fibrin derivative (D-dimer), which is specific for fibrin breakdown. RESULTS In 82 (32.8%) patients, deep vein thrombosis was confirmed venographically. An abnormal D-Dimer test was found in 79 of the 82 patients with thrombosis (sensitivity: 96.3%). The three patients who were diagnosed falsely as normal on agglutinin testing, had venograms which showed only an isolated calf thrombosis in small muscle veins (< 2 cm in diameter) not requiring treatment. One hundred of 168 patients without venographic thrombosis were diagnosed correctly by SimpliRED (specificity: 59.5%). The positive predictive value was 53.7%; the negative predictive value was 96.8%. CONCLUSIONS All thrombotic disorders in the leg that required further treatment were identified correctly. SimpliRED is a very sensitive test with moderate specificity in the diagnosis of deep vein thrombosis. Therefore, further invasive testing is needed only in those patients in whom the D-dimer test is abnormal. A false-positive result of the bedside test may be nonspecific or due to elevated levels of fibrin split products, which can occur whenever the coagulation system has been activated by any of several conditions.

Skeletal maturity determination from hand radiograph by model-based analysis

Derived from a model based segmentation algorithm for hand radiographs proposed in our former work we now present a method to determine skeletal maturity by an automated analysis of regions of interest (ROI). These ROIs including the epiphyseal and carpal bones, which are most important for skeletal maturity determination, can be extracted out of the radiograph by knowledge based algorithms.

Guidelines for cost-effective implementation of picture archiving and communication systems an approach building on practical experiences in three European hospitals

This paper describes a comprehensive approach for the assessment of the impact of (partial) Picture Archiving and Communication Systems (PACS). The approach is developed, based on actual clinical experience in three European hospitals and tested in these environments. The approach departs from a thorough analysis of the working procedures and information flows before implementation, both descriptive and quantitative. On the basis of this analysis, quantitative (and hence testable) objectives of the implementation are defined. The implementation strategy is defined after comparison of various scenarios, taking costs and effects for both the final and the transition phases into account. The approach is supported by a comprehensive evaluation protocol and a software package (PACER). The approach is demonstrated in this paper by applying it on a hypothetical PACS implementation for CT, ultrasound and for the part of the radiology department serving ICU. The objectives of this PACS are: (1)--to shorten the turn around time between the radiology department and ICU from 4 h to 30 min, (2)--to save 2000 m2 of film per year and (3)--to save personnel time. In this case the PACS is introduced in three phases and completed after three years. The cost analysis shows that, if started in 1995, a financial break even point is reached after 6 years, when comparing costs for the film-based system with those of the PACS. Experiences in the three sites show that the approach helps to harvest potential benefits, allowing a cost-effective implementation of PACS.

Dynamic GD-enhanced MR imaging of hepatic hemangioma: Is high temporal resolution requisite for characterization?

We assessed the value of high temporal resolution in the dynamic characterization of hepatic hemangioma with use of magnetization-prepared gradient-echo (MP-GRE) imaging. Single-level inversion recovery incremental flip angle MP-GRE images were obtained in 26 patients with 34 hemangiomas before and at a repetition rate of 30 images/min after injection of Gd-DTPA without breath-holding. Enhancement patterns and temporal changes thereof were analyzed. Hemangiomas were categorized as small ( < 2.0 cm), medium (2.0-5.0 cm), and large ( > 5 cm) lesions. Classic early peripheral nodular enhancement (PNE) with progressive hyperintense fill-in was observed in 31 lesions (91%). Two of 10 small and 1 of 20 medium lesions showed complete fill-in within 10 s, and three small and one medium lesions within 45 s after the onset of PNE. In no cases of hemangioma was immediate homogenous hyperintensity observed without preceding PNE. In conclusion, temporal resolution of less than 10 s is a prerequisite for confident dynamic characterization of some hemangiomas, predominantly small hemangiomas.

Model based analysis of chest radiographs

Chest radiographs represent a difficult class of images concerning automatic analysis with image processing methods. In our former work we presented a model based method to detect the rib borders and implemented a compensation algorithm of the rib structures. Recently we developed an improved method for rib border detection and algorithms to find the objects like chest border, vertebral spine, heart and intravascular catheter within a model driven approach. The determined borders of these objects allow further analysis and image enhancement for diagnose assistance.

Knowledge-based automated feature extraction to categorize secondary digitized radiographs

An essential part of the IRMA-project (Image Retrieval in Medical Applications) is the categorization of digitized images into predefined classes using a combination of different independent features. To obtain an automated and content-based categorization, the following features are extracted from the image data: Fourier coefficients of normalized projections are computed to supply a scale- and translation-invariant description. Furthermore, histogram information and Co-occurrence matrices are calculated to supply information about the gray value distribution and textural information. But the key part of the feature extraction is the shape information of the objects represented by an Active Shape Model. The Active Shape Model supports various form variations given by a representative training set; we use one particular Active Shape Model for each image class. These different Active Shape Models are matched on preprocessed image data with a simulated annealing optimization. The different extracted features were chosen with regard to the different characteristics of the image content. They give a comprehensive description of image content using only few different features. Using this combination of different features for categorization results in a robust classification of image data, which is a basic step towards medical archives that allow retrieval results for queries of diagnostic relevance.

Laboratory Investigations[cmFragmentation of Pulmonary Emboli: In Vivo Experimental Evaluation of Two High-Speed Rotating Catheters

AbstractPurpose: To test two over-the-wire systems for fragmentation of pulmonary emboli. Methods: In 11 dogs, 22 embolic occlusions of lobar or central pulmonary arteries were performed by injection of preformed emboli through a jugular vein sheath. A commercially available device (thrombolizer) and a modified version of the impeller catheter were introduced via the femoral vein and positioned at the embolus site. Results: Catheter placement at the site of the emboli was possible. In more than half of the cases a hydrophilic or an extra-stiff guidewire was necessary. The thrombolizer did not rotate properly with its original pneumatic drive and required a major modification. When sufficient rotation was provided, both fragmentation catheters were able to clear the occluded main arteries. Side branches were partly obstructed by the resulting fragments. Recanalization led to a reduction of the emboli-induced elevation of the pulmonary arterial pressure by two-thirds. Histology of the recanalized pulmonary artery segments revealed localized (impeller catheter) and widespread (thrombolizer) periarterial hemorrhage. Conclusion: Embolus fragmentation led to a hemodynamic improvement. The impeller catheter was less traumatic compared with the thrombolizer, which was technically insufficient.