Patrick Krumm

Depiction of Variants of the Portal Confluence Venous System Using Multidetector Row CT: Analysis of 916 Cases

PURPOSE Detailed knowledge of the venous mesenteric system is important for gastrointestinal surgery, particularly for transplantation planning and surgery and for the comprehension of perioperative complications that may influence patient outcome. Data about the mesenteric venous anatomy in the literature varies substantially. The purpose of this study was to categorize venous mesenteric variants and to determine their incidence. MATERIALS AND METHODS We included 916 patients requiring diagnostic abdominal CT in the portal venous phase. The mesenteric vein anatomy was categorized as follows: 1. the inferior mesenteric vein (IMV) enters the splenic vein (SV); 2. the IMV enters into the angle of the confluence of the SV and superior mesenteric vein (SMV) forming the portal vein (PV); 3. the IMV enters the SMV; 4. seven rare variants. We measured the diameters of the veins and distances from the confluence to the IMV origins. RESULTS The frequency of variants was: 1. 37.6%, 2. 28.8%; 3. 19.2%. The rare variants totaled 14.4%. The average vessel diameters measured in cm: PV 1.48; SV 1.02; SMV 1.2; IMV 0.5. The mean IMV entering distances were 1.66 cm in variant 1 and 0.75 cm in variant 3. CONCLUSION The three common variants (1, 2 and 3) are the most relevant ones. 14.4% of patients had different anatomic variants. The variability of the mesenteric venous system was higher than previously published. Knowledge of rare variants is important to avoid complications in abdominal surgery.

Reverse left ventricular remodeling after percutaneous mitral valve repair: Strain analysis by speckle tracking echocardiography and cardiac magnetic resonance imaging

Strain analysis by speckle tracking echocardiography and cardiac magnetic resonance imaging Christine S. Zuern , Patrick Krumm , Thomas Wurster , Ulrich Kramer , Jürgen Schreieck , Andreas Henning , Axel Bauer , Meinrad Gawaz , Andreas E. May a,⁎ a Medizinische Klinik III, Eberhard Karls Universität Tübingen, Germany b Diagnostische und Interventionelle Radiologie, Eberhard Karls Universität Tübingen, Germany

Is myocardial stress perfusion MR-imaging suitable to predict the long term clinical outcome after revascularization?

INTRODUCTION Aim of our study was to evaluate, whether myocardial ischemia or myocardial infarction (MI) depicted by myocardial stress perfusion MR imaging (SP CMR) can predict the clinical outcome in patients with coronary artery disease (CAD). MATERIALS AND METHOD 220 patients were included. Myocardial perfusion was assessed at stress and at rest, using a 2D saturation recovery gradient echo sequence (SR GRE) and myocardial viability by late gadolinium enhancement magnetic resonance images (LGE CMR). MR-images were assessed in regard of presence and extent of MI and ischemia. Patients were monitored for major adverse cardiac events (MACE) (monitoring period: 5-7 years). MACE were correlated with the initial results of SP CMR. RESULTS Ischemia was found in 143 patients, MI in 107 patients. Number of MACE was in patients with normal SP CMR 0 (51 patients), with ischemia 21 (62 patients), with MI 14 (26 patients), with ischemia and MI 52 (81 patients). In all patients with severe MACE (MI, death) and in 63 of those with recurring symptoms LGE CMR revealed MI at baseline. CONCLUSION Negative SP CMR indicates low risk for MACE. In patients with stress induced ischemia, MACE might occur even after myocardial revascularization. The presence of MI proved by LGE CMR is associated with a significantly increased risk for MACE.

Speech and swallowing abnormalities in adults with POLG associated ataxia (POLG-A)

BACKGROUND Mutations in the nuclear-encoded mitochondrial DNA polymerase gamma (POLG) can result in a wide spectrum of neurological deficits. A common presentation is progressive ataxia (POLG-A) which includes impaired speech and swallowing. The nature, severity and impact of these deficits in POLG-A is not known. A comprehensive quantitative and qualitative characterization of dysarthria and dysphagia in this recurrent ataxia disorder will assist in diagnostics, provide insights into the underlying pathology, and establish the foundation for future therapy trials. METHODS 14 consecutive patients with POLG (9 females, mean age=50.1y, SD=11.2) and 34 healthy controls were enrolled. Comprehensive assessments of motor speech and swallowing function, acoustic analysis of speech, videofluoroscopy and measures of quality of life were conducted. RESULTS The speech profile of individuals with POLG-A was characterized by poor control of pitch and strain-strangled voice quality, reduced rate of speech and longer variable silences between words, and articulatory breakdown including imprecise consonants and vowel distortions. Swallowing deficits included slower initiation of the swallow reflex, poor control of bolus and late epiglottic closure. Speech and swallowing related quality of life was worse than healthy controls. CONCLUSIONS The dysarthria and dysphagia profiles in POLG-A are largely symptomatic of impaired timing, indicating a mainly spinocerebellar deficit. Dysarthria and dysphagia contribute to a significant impairment in functional quality of life, and progress distinctly from other POLG-A dysfunctions like ataxia or cognitive impairment. Our assessments establish meaningful patient focused outcome measures that will be suitable for use in natural history studies and clinical trials.

Signal decay mapping of myocardial edema using dual‐contrast fast spin‐echo MRI

To introduce a dual‐contrast fast spin‐echo (dcFSE) sequence for signal decay mapping of myocardial edema.

Clinical use of cardiac PET/MRI: current state-of-the-art and potential future applications

Combined PET/MRI is a novel imaging method integrating the advances of functional and morphological MR imaging with PET applications that include assessment of myocardial viability, perfusion, metabolism of inflammatory tissue and tumors, as well as amyloid deposition imaging. As such, PET/MRI is a promising tool to detect and characterize ischemic and non-ischemic cardiomyopathies. To date, the greatest benefit may be expected for diagnostic evaluation of systemic diseases and cardiac masses that remain unclear in cardiac MRI, as well as for clinical and scientific studies in the setting of ischemic cardiomyopathies. Diagnosis and therapeutic monitoring of cardiac sarcoidosis has the potential of a possible ‘killer-application’ for combined cardiac PET/MRI. In this article, we review the current evidence and discuss current and potential future applications of cardiac PET/MRI.

Cardiac MRI Left Ventricular Global Function Index and Quantitative Late Gadolinium Enhancement in Unrecognized Myocardial Infarction

PURPOSE To compare left ventricular global function index (LVGFI) and quantitative late gadolinium enhancement (LGE) in patients with unrecognized myocardial infarction (UMI), recognized myocardial infarction (RMI) and without myocardial infarction (MI). MATERIAL AND METHODS Under waiver of the Institutional Review Board 235 patients (age 63.5±10.5years, 57 female) were retrospectively evaluated. All patients had undergone cardiac MRI at 1.5T for symptoms of CAD. 67 patients (29%) had suffered a known RMI before. Functional imaging and full-intensity late gadolinium enhancement (LGE) imaging were evaluated for LVGFI and quantitative LGE mass. RESULTS Of 168 patients without history of RMI, 48 patients (29%) had UMI, 120 patients had no MI. LVGFI was lower in RMI patients (34±8% [range 16;52]), and UMI patients (35±8% [range 10;51]), compared to patients with no MI (38±7% [range 16;55]) respectively and similar between RMI and UMI patients. RMI patients had full-intensity LGE in 11±6% of left ventricular myocardial mass (LVMM). UMI patients had LGE in 9±5% of LVMM. RMI patients had significantly more LGE than UMI patients (p=0.0096). CONCLUSION LGE quantification is effective to assess infarction scar size in RMI and UMI patients. LVGFI provides information on cardiac function and morphology but does not allow for a reliable differentiation between patients with and without history of MI, due small differences and wide overlap of LVGFI values for all three patient groups. This may be a reason why LVGFI is not applied in clinical routine.

Imaging giant cell arteritis and Aortitis in contrast enhanced 18F-FDG PET/CT: Which imaging score correlates best with laboratory inflammation markers?

PURPOSE To define the most appropriate imaging parameters in combined Fluorodeoxyglucose (FDG) PET/CT reflecting the inflammatory burden in large vessel vasculitis. METHODS Two readers retrospectively graded disease extent and activity in 17 LVV patients using visual and quantitative scores in FDG PET and contrast enhanced CT. Visual PET scores were assessed corresponding to FDG-uptake vs. liver uptake (score 0-3). CT visual scoring referred to the affected vessel extent (score 1-5). Quantitative PET scores relied on normalized SUV ratios. For quantitative CT evaluation vessel wall thickness was correlated with FDG- uptake. Imaging scores were correlated with Erythrocyte Sedimentation Rate (ESR) and C-reactive protein (CRP). Intraclass correlation coefficients (ICC) were measured for interreader reliability. RESULTS Visual PET scores showed stronger correlation with CRP (ρ 0.640, 0.541 for reader I and II, respectively) than with ESR levels (ρ 0.477, 0.447). Quantitative PET showed strongest correlation with CRP using liver as reference tissue. Visual CT scores did neither correlate with ESR nor with CRP levels (ESR: ρ 0.085, 0.294 with p 0.743, 0.252; CRP: ρ 0.322, 0.395 with p 0.208, 0.116). Quantitative CT evaluation correlated with ESR levels in one reader (ρ 0.505, -0.026), however no correlation between quantitative CT measures and quantitative PET scores was found. Best ICC between readers was 0.994 for highest SUVavg vessel/highest SUVavg liver. CONCLUSIONS Visual and quantitative PET scores were superior to CT scores with best ICC and strongest correlations between quantitative PET score and inflammation markers especially when using vessel to liver ratios.

Single-Breath-Hold Evaluation of Cardiac Function with Use of Time-Resolved Parallel Cardiac Magnetic Resonance

Using cardiac magnetic resonance, we tested whether a single-breath-hold approach to cardiac functional evaluation was equivalent to the established multiple-breath-hold method. We examined 39 healthy volunteers (mean age, 31.9 ± 11.4 yr; 22 men) by using 1.5 T with multiple breath-holds and our proposed single breath-hold. Left ventricular and right ventricular ejection fractions (LVEF and RVEF), LV and RV end-diastolic volumes (LVEDV and RVEDV), and LV myocardial mass (LVMM) were compared by using Bland-Altman plots; LVEF and RVEF were tested for equivalence by inclusion of 95% confidence intervals (CIs). Equivalence of the methods was assumed within the range of -5% to 5%. In the multiple- versus the single-breath-hold method, LVEF was 0.62 ± 0.05 versus 0.62 ± 0.04, and RVEF was 0.59 ± 0.06 versus 0.59 ± 0.07. The mean difference in both methods was -0.2% (95% CI, -1 to 0.6) for LVEF and 0.3% (95% CI, -0.8 to 1.5) for RVEF. The mean differences between methods fit within the predetermined range of equivalence, including the 95% CI. The mean relative differences between the methods were 3.8% for LVEDV, 4.5% for RVEDV, and 1.6% for LVMM. Results of our single-breath-hold method to evaluate LVEF and RVEF were equivalent to those of the multiple-breath-hold technique. In addition, LVEDV, RVEDV, and LVMM showed low bias between methods.

Cardiac magnetic resonance tomography in the diagnostics of restrictive and unclassified cardiopathies

CLINICAL/METHODICAL ISSUE Besides ischemic heart disease cardiomyopathies are common causes of heart failure and sudden cardiac death. STANDARD RADIOLOGICAL METHODS The diagnostic spectrum in cardiomyopathies comprises non-invasive and invasive examination techniques. METHODICAL INNOVATIONS The exact verification of certain cardiomyopathies necessitates knowledge of the latest classification of cardiomyopathies as well as dedicated examination protocols. PERFORMANCE Modern imaging modalities, such as echocardiography and cardiac magnetic resonance imaging (MRI) have emerged as useful imaging tools in the investigation of patients suspected of having many different types of cardiomyopathies. ACHIEVEMENTS Based on a better understanding of the underlying pathophysiology several diagnostic criteria have been defined using cardiac MRI. In particular there is an increasing importance of cardiac MRI in the description of patients with restrictive and unclassified cardiomyopathies. PRACTICAL RECOMMENDATIONS Echocardiography still remains the modality of choice in the diagnostics of unclear left ventricular heart failure. Further diagnostic work-up should include cardiac MRI in case of any lack of clarity.ZusammenfassungKlinisches/methodisches ProblemKardiomyopathien stellen neben den ischämischen Herzerkrankungen eine wesentliche Ursache für die Entwicklung einer Herzinsuffizienz und den plötzlichen Herztod dar.Radiologische StandardverfahrenDas diagnostische Spektrum bei Kardiomyopathien umfasst nichtinvasive und invasive Untersuchungsmethoden.Methodische InnovationenDie exakte Diagnosesicherung einzelner Krankheitsbilder erfordert zum einen die Kenntnis der aktuellen Klassifikationen der heterogenen Gruppe der Kardiomyopathien, zum anderen sind oft spezielle Untersuchungstechniken erforderlich.LeistungsfähigkeitModerne bildgebende Verfahren stellen einen zentralen Bestandteil der diagnostischen Möglichkeiten bei der Abklärung einer Kardiomyopathie dar. Neben der Echokardiographie ist hier insbesondere die kardiale Magnetresonanztomographie (MRT) zu nennen.BewertungMit zunehmendem Verständnis über die Pathogenese einzelner Kardiomyopathien konnten diagnostische Kriterien für die kardiale MRT definiert werden, weshalb heute ein regelmäßiger Einsatz der MRT zur Differenzierung einer restriktiven oder unklassifizierten Kardiomyopathie gerechtfertigt ist.Empfehlung für die PraxisDie Echokardiographie ist das bildgebende Verfahren der Wahl bei der Abklärung einer unklaren Herzinsuffizienz. Die kardiale MRT sollte jedoch bei Unklarheiten frühzeitig in den diagnostischen Algorithmus eingebunden werden.AbstractClinical/methodical issueBesides ischemic heart disease cardiomyopathies are common causes of heart failure and sudden cardiac death.Standard radiological methodsThe diagnostic spectrum in cardiomyopathies comprises non-invasive and invasive examination techniques.Methodical innovationsThe exact verification of certain cardiomyopathies necessitates knowledge of the latest classification of cardiomyopathies as well as dedicated examination protocols.PerformanceModern imaging modalities, such as echocardiography and cardiac magnetic resonance imaging (MRI) have emerged as useful imaging tools in the investigation of patients suspected of having many different types of cardiomyopathies.AchievementsBased on a better understanding of the underlying pathophysiology several diagnostic criteria have been defined using cardiac MRI. In particular there is an increasing importance of cardiac MRI in the description of patients with restrictive and unclassified cardiomyopathies.Practical recommendationsEchocardiography still remains the modality of choice in the diagnostics of unclear left ventricular heart failure. Further diagnostic work-up should include cardiac MRI in case of any lack of clarity.