Stefan Puig

Usefulness of magnetic resonance imaging of cardiac and paracardiac masses

In this study, magnetic resonance imaging was compared with histology to evaluate the usefulness of magnetic resonance imaging to distinguish malignant from benign cardiac and paracardiac masses in 55 patients. Tumor location, tissue composition, and pericardial or pleural effusion all were identified as key predictors of lesion type. Observers were accurate in the prediction of lesion type (area under curve 0.88 and 0.92), and there was good interobserver variability (Cohens kappa = 0.64).

Classification of venous malformations in children and implications for sclerotherapy

Abstract Objective. The purpose of this work is to present a simple and descriptive classification system for venous malformations (VMs) that may serve as a basis for interventional therapy, and to test its usefulness in a sample of consecutively referred paediatric patients. Materials and methods. The classification system we developed includes four types: type I, isolated malformation without peripheral drainage; type II, malformation that drains into normal veins; type III, malformation that drains into dilated veins; and type IV, malformation that represents dysplastic venous ectasia. The system was prospectively tested using phlebography in a sample of 43 children and adolescents with VMs who were referred for treatment during a 10-month period. Our hypothesis was that the type of VM would determine whether low-risk sclerotherapy was indicated. Results. Thirteen (30%) patients had a type-I VM, 16 (37%) had a type-II, 9 (21%) had a type-III, and 5 (12%) had a type-IV malformation. In more than 90% of patients with a type-I or type-II lesion, sclerotherapy could be performed without any problems. In one third of patients with a type-III VM, sclerotherapy had to be withheld and one of nine (11%) developed a severe complication after therapy. Of the five patients with type-IV lesions, three (60%) had to be excluded from sclerotherapy. Conclusions. Our initial results indicate that sclerotherapeutic intervention in patients with type-III and type-IV VMs must be carefully considered, while it can be safely performed in low-risk patients with type-I and type-II lesions.

Comparison and histopathological correlation of three parathyroid imaging methods in a population with a high prevalence of concomitant thyroid diseases

The aim of this prospective study was to evaluate the diagnostic utility of a technetium-99m sestamibi dual-phase protocol enhanced by single-photon emission tomography (SPET) and semiquantitative analysis in comparison to established preoperative staging procedures in patients with primary hyperparathyroidism. Twenty-eight (50%) out of 56 patients had superimposed thyroid disease, and 12 patients had previously undergone neck surgery. Visual and semiquantitative analysis of planar99mTc-sestamibi dual-phase imaging, SPET of the delayed phase, ultrasonography, and thallium-201 chloride-technetium-99m pertechnetate subtraction scintigraphy was further correlated with the histopathological examination of the surgical specimens.99mTc-sestamibi dual-phase imaging achieved the highest sensitivity for side localization and precise localization compared with201Tl-99mTc subtraction scintigraphy and ultrasonography, but the differences reached statistical significance only in comparison to ultrasonography. Semiquantitative analysis did not enhance sensitivity. Adenoma detection by99mTc-sestamibi dual-phase imaging was only correlated to serum calcium levels and osteocalcin, not to cell density or oxyphil cell count (SPET yielded additional information for the exact topographical localization of the parathyroid tumour in 22 (39%) patients with superimposed thyroid disease or previous neck surgery but did not enhance the overall detection rate.

Pulmonary echinococcosis (hydatidosis) in children: Results of surgical treatment

From 1986–1996, 33 children with 49 pulmonary hydatid cysts underwent surgical treatment in Vienna and Istanbul. Cysts were unilateral in 28 and bilateral in 5 cases; unruptured cysts (URC) were diagnosed in 19 patients, and 14 children presented with ruptured cysts (RC). Ten patients had cysts in other organs (liver, spleen, central nervous system) in addition to pulmonary cysts. Diagnosis was primarily based on chest X‐ray and computed tomography scan. In Austrian children, a new combination of serological tests was used successfully (71% positive).

Imaging articular cartilage defects in the ankle joint with 3D fat-suppressed echo planar imaging: Comparison with conventional 3D fat-suppressed gradient echo imaging

To shorten the examination time for articular cartilage imaging, using a recently developed three‐dimensional (3D) multishot echo planar imaging (EPI) sequence with fat saturated (FS), compared to aconventional 3D fat‐saturated spoiled gradient echo sequence (3D FS GRE).

Does 99mTc-Sestamibi in High-Grade Malignant Brain Tumors Reflect Blood–Brain Barrier Damage Only?

(99m)Tc-Sestamibi (MIBI) has been successfully applied in recurrent glioblastoma. The aim of this study was to evaluate the incremental diagnostic information of MIBI as a tumor-avid radiopharmaceutical compared with (99m)Tc-pertechnetate ((99m)Tc) as sole indicator of the integrity of the blood-brain barrier. Twenty-five patients with confirmed recurrent brain tumors were included. MIBI SPET was performed 10 min after injection of 555 MBq MIBI intravenously with a triple-headed gamma camera equipped with LE-UHR-PAR collimators over 360 degrees (3 degrees /step) and stored in a 128(2) matrix. Identical acquisition parameters were used for (99m)Tc SPET, which was acquired 3 h after injection of 740 MBq (99m)Tc. Normalized tumor uptake (NU) was calculated from attenuation-corrected transaxial slices. In addition, tumor/plexus, tumor/nasopharynx, and tumor/parotid gland ratios were assessed in both studies. No statistically significant differences were detected for the mean NU of tumor tissue with MIBI (0.26 +/- 0.10) and (99m)Tc (0.39 +/- 0. 33) and for the tumor/nasopharynx and tumor/parotid gland ratios; only the tumor/plexus ratio was significantly higher for (99m)Tc than for MIBI (p < 0.05). In conclusion, our data indicate that MIBI scintigraphy in brain tumors at 10 min postinjection reveals no additional visual information over that provided by the conventional (99m)Tc-pertechnetate brain scan, and in addition, tracer retention reflects primarily blood-brain barrier damage.

Single- and multi-slice spiral computed tomography of the paediatric kidney

Single- and multi-slice computed tomography (CT) is regarded as the primary imaging tool in traumatology, both in adults and children. For complicated infectious disease and renal tumours, these techniques are recommended only as secondary diagnostic tools. Specifically, multi-slice CT (MSCT) provides excellent spatial resolution, which is a particular advantage for the evaluation of small structures as they are typical in children. However, MSCT offers more information than is required for diagnosis. Therefore, low-dose protocols are necessary for paediatric examinations. The CT dose-index (CTDI(vol)) should not exceed 2 mGy for newborns, 4 mGy for toddlers, 5 mGy for elementary school children, and 8 mGy for adolescents.

Thoraxröntgen beim neonatologischen Patienten

ZusammenfassungIn der bildgebenden Diagnostik thorakaler Pathologien bei reifen und insbesondere unreifen Neugeborenen steht das Thoraxröntgenbild an erster Stelle. Profunde Kenntnisse des normalen Thoraxbilds und der möglichen physiologischen peripartalen Veränderungen sind Voraussetzung für die Interpretation der neonatologischen Thoraxaufnahme. Kindliche Pathologien: Eine Vielzahl von kongenitalen und erworbenen Veränderungen, mit denen der Radiologe in der Neonatologie konfrontiert ist, sind in der Radiodiagnostik des erwachsenen Patienten unbekannt. Viele dieser Veränderungen sind für den Patienten lebensbedrohlich oder können die Lebensqualität in seinem weiteren Leben beeinflussen. Eine frühzeitige Diagnostik in enger Zusammenarbeit mit dem Pädiater ist daher essenziell. Hier wird ein Überblick über die wichtigsten Pathologien, mit denen der Radiologe in der täglichen Routine konfrontiert sein kann, gegeben.SummaryIn diagnostic imaging of thoracic pathologies in mature and especially immature neonates, chest X-ray has a leading position. Profound knowledge of the normal chest X-ray and the potential physiological perinatal changes is the basic requirement for interpretation of the X-ray of a neonate. Childhood pathologie: Many congenital and acquired diseases that the radiologist is faced with in neonatology are unknown in the imaging of adults. Many of these changes are life-threatening or may have an impact on the patient’s future quality of life. Therefore early diagnosis in close cooperation with the paediatrician is essential. We give here an overview of the most important pathologic changes that the radiologist may be con- fronted with in daily routine.

Appendicoliths and appendectomy in the pediatric population

ZusammenfassungGRUNDLAGEN: Kotsteine der Appendix sind eine bekannte Ursache für die Appendizitis. Das Vorhandensein eines Appendikolithen per se könnte daher eine Indikation zur Appendektomie darstellen. METHODIK: Retrospektive Untersuchung über einen Zeitraum von 6 Jahren aller Blinddarmoperationen. Verlauf und Diagnose wurden in Bezug auf das Vorhandensein eines Appendikolithen für verschiedene pädiatrische Altersgruppen erhoben. Diese wurden in folgende Gruppen eingeteilt: 0–4 Jahre, 4–6 Jahre, 6–10 Jahre, 10–14 Jahre, 14–18 Jahre, sowie 3 Kategorien (keine Blinddarmentzündung, Blinddarmentzündung, Perforation) zugeordnet. ERGEBNISSE: Neunhundertneunzig Patienten waren inkludiert. Die Inzidenz eines Appendikolithen betrug 28,6%, bei 4–6 jährigen 37,6%. Appendikolithen führten signifikant häufiger zur Perforation (odds ratio 2,27; p < 0,0001), in den Altersgruppen 0–6 Jahre vs 6–18 Jahre betrug die odds ratio: 10,2; (p < 0,0001). Der präoperative Krankheitsverlauf ist signifikant hänger in der Gruppe ohne Appendikolith (p = 0,04). SCHLUSSFOLGERUNGEN: Appendikolithen sind ein hoch signifikanter Faktor für das Auftreten einer spontanen Perforation. Das rechtfertigt die Appendektomie zur Vermeidung der Perforation bei zufällig entdecktem Appendikolith.SummaryBACKGROUND: Improved diagnostic techniques increase the number of incidental findings of appendicoliths even without any patient complaints. Appendicoliths are one cause for appendicitis, and seem to justify elective appendectomy. METHODS: Retrospective evaluation of all patients who underwent appendectomy within a period of 6 years. Stratification into 5 groups: 0–4, 4–6, 6–10, 10–14 and 14–18 years and categorization into 3 possible outcomes: no appendicitis, appendicitis, perforated appendicitis. RESULTS: Nine hundred and ninety patients were included. The incidence of appendicoliths was 28.6%, rising to 37.6% in preschool children. Appendicoliths were strongly associated with appendiceal rupture (odds ratio totally: 2.27; p < 0.0001; age group 0–6 years vs 6–18 years odds ratio: 10.2; p < 0.0001). Preoperative history was significantly higher in patients without appendicolith (p = 0.04). CONCLUSIONS: Appendicoliths are significantly associated with spontaneous perforation. Therefore elective appendectomy in the presence of an appendicolith is justified to avoid perforation.

Acute hemorrhagic respiratory failure caused by Wegener’s granulomatosis successfully treated by bronchoalveolar lavage with diluted surfactant

ZusammenfassungWegener Granulomatose (WG) ist eine idiopathische entzündliche Systemerkrankung, die mitunter zum Lungenversagen führen kann. Wir berichten über die erfolgreiche Behandlung einer jugendlichen Patientin mit Wegener Granulomatose mit diffuser Lungenblutung mittels Bronchiallavage mit verdünntem Surfactant. Die Lavage mit verdünntem porcinem Surfactant (Curosurf®, Chiesi, Parma, Italien; 4,8 mg/mL) und die anschließend durchgeführte Bolusgabe erfolgte mittels einem flexiblem Bronchoskop selektiv in beide Lungen. Die verabreichte Gesamtdosis betrug 40 mg/kg KG. Die Patientin war während der gesamten Bronchiallavage beatmet und hämodynamisch stabil, es wurde nur ein kurzer Abfall der pulsoxymetrischen Sättigung beobachtet. Das PaO2/FiO2 Verhältnis stieg von 54,8 auf 62,4 nach einer Stunde, auf 106 nach 17 Stunden und erreichte schließlich 280 am 4. Tag nach Therapie. Am Tag 5 nach Therapie konnte die Patientin extubiert werden. Bei Entlassung nach 8 Wochen wurde eine normale Lungenfunktion ermittelt. Die bronchoskopische Lavage mit verdünntem Surfactant ermöglicht eine selektive und direkte Form der Medikamtenapplikation und zusätzlich die Reinigung der Atemwege von Blut und Zelldebris. Diese Reinigung führt zu einer wesentlichen Verminderung der inhibitorischen Kapazität und dadurch zu einem wesentlich geringeren Bedarf an Surfactant. Wir schließen aus dem vorliegenden Fall, dass die frühe Surfactanttherapie mittels BAL zur Vermeidung invasiver Behandlungsmethoden wie ECMO, und damit zu einer schnelleren Wiederherstellung der Lungenfunktion, wesentlich beitragen könnte.SummaryWegener’s granulomatosis (WG) is an idiopathic inflammatory systemic disease that can occasionally cause an acute respiratory distress syndrome. We report on a 17-year-old girl with Wegener’s granulomatosis and acute hemorrhagic respiratory failure successfully treated using bronchoalveolar lavage with diluted porcine surfactant (Curosurf®; 4.8 mg/mL) followed by a low-dose bolus of surfactant. The cumulative dose of surfactant was 40 mg/kg BW. The lavage with diluted surfactant and the administration of the bolus were performed with a flexible bronchoscope. The patient was ventilated during the whole procedure, stayed hemodynamically stable and showed only a very short phase of desaturation. The PaO2/FiO2 ratio increased from 54.8 to 62.4 after one hour, to 106 after 17 hours and finally to 280 after four days. The patient was extubated five days after lavage treatment, and almost normal lung function was restored after eight weeks.Bronchoalveolar lavage with diluted surfactant by flexible bronchoscopy allows selective and direct drug administration and removes airway and alveolar debris. The technique reduces the amount of surfactant needed to overcome inhibition and thereby reduces therapy costs. We conclude that this early therapeutic intervention with surfactant might help to avoid an invasive rescue therapy such as extra corporeal membrane oxygenation, thus improving outcome in terms of faster recovery of lung function.